Pulmonary tuberculosis with atypical radiological findings in a patient with chronic obstructive pulmonary disease

A 77-year-old-man who had been treated for chronic obstructive pulmonary disease (COPD) was referred to our hospital for further examination of a chest X-ray abnormality. The chest X-ray showed consolidation in the right upper and middle lung field. Chest computed tomography showed an airspace consolidation extending subpleurally and nonsegmentally without nodular lesions. The tentative diagnosis was cryptogenic organizing pneumonia. However, bronchoalveolar lavage fluid was positive for acid-fast bacilli on smear and also positive for tuberculosis PCR, leading to a diagnosis of tuberculous pneumonia. Tuberculous pneumonia in COPD patients can be non-segmental and mimic organizing pneumonia.     

Identification of propionibacterium acnes in a case with stage III pulmonary sarcoidosis involving hepatosplenic disease]

A 35-year-old woman was admitted to our hospital because of an abnormal chest radiograph. Chest X-ray on admission showed multiple small nodular shadows in both lung fields but no bilateral hilar lymphadenopathy (BHL). Moreover, abdominal CT showed some nodules in the liver and spleen, and serum ACE was slightly increased to 23.3U/L (normal range: 8.3-21.4U/L). Transbronchial lung biopsy and liver biopsy resulted in a diagnosis of stage III pulmonary sarcoidosis with hepatosplenic disease. Histopathological findings demonstrated non-caseating epithelioid cell granulomas with giant cells in both specimens. Interestingly, propionibacterium acnes (P. acnes), the possible pathogen of sarcoidosis, was detected in giant cells in the lung and epitheliod cell granuloma of liver tissue. This case was of interest considering P. acnes might have been the causative pathogen.     

A case of miliary tuberculosis with cutaneous lesion

Miliary tuberculosis associated with cutaneous lesion has been rarely reported. We report a case of miliary tuberculosis in whom the cutaneous lesion was confirmed as tuberculosis by skin biopsy and bacterial examination. A 46-year-old man was admitted because of cough, fever, sore throat and abnormal shadow on the chest X-ray. Physical examination revealed an emaciated man with two ulcerous lesions overlying yellowed crust on the chest wall and fine crackles on the left side of the lung. Laboratory workup revealed a white blood cell count of 10,000 with 15% lymphocytes and positive CRP. Chest X-ray film showed the infiltration with cavity formation in left upper lung field and nodular dissemination. His tuberculin reaction was negative on admission. Sputum, urine and secrete from cutaneous lesion were positive for the acid-fast bacilli and the culture grew Mycobacterium tuberculosis. Examination of the skin biopsy specimen and bone marrow aspiration showed Langhans giant cells around necrotic lesion; therefore the diagnosis of miliary tuberculosis was made. After an initiation of antituberculosis therapy with combined regimen composed of streptomycin (SM), isoniazid (INH), ethambutol (EB) and rifampicin (RFP), this patient improved significantly. Although the case report of miliary tuberculosis tends to increase recently, the report of cutaneous lesion is relatively rare in association with miliary tuberculosis. We discussed this subject with reference to the literatures.     

A case of M. fortuitum lung disease with small-cell lung cancer]

A 58-year-old man was admitted to our hospital because of an abnormal shadow found on chest radiography. Chest radiographs and chest CT on admission showed a bulla with a niveau and infiltration in the right upper lobe. Smear of sputum and bronchial lavage were negative for acid-fast bacilli. Despite treatment with meropenem and clindamycin, the infiltrating shadow worsened. Since bronchial lavage and sputum culture were positive for M. fortuitum, these drugs were replaced with minocycline and imipenem. Thereafter, the shadow on the chest radiograph improved. After discharge, outpatient treatment with clarithromycin and levofloxacin was continued. After 4 months, the residual tumor shadow in the right upper lobe gradually grew. When a CT-guided transcutaneous needle lung biopsy was undertaken, malignant cells were found. Right upper lobectomy was performed. Pathological examination of the lesion demonstrated small-cell lung cancer. If a lesion does not change after nontuberculous mycobacteria treatment, the physician should consider other lesions such as lung cancer.     

A case of localized pleural tuberculosis exacerbated during antituberculous chemotherapy

A 24 year-old male with pulmonary tuberculosis in right upper lobe developed two lesions of extrapulmonary pleural tuberculoma during the course of antituberculous therapy. He had no history of lung tuberculosis nor pleurisy. However, the chest X-ray film on first admission showed scattered nodular shadows in right upper lung field. He had no subjective symptoms and no abnormalities of laboratory findings except mild iron deficiency anemia, from which he recovered completely without specific therapy. Three months after starting the antituberculous therapy including SM, INH, and RFP, a new round homogeneous opacity appeared in the right lower lung field (S4). Chest CT scan revealed the lesions in S10 as well as in S4. Microscopic examination of the specimen obtained by ultrasound-guided needle aspiration biopsy disclosed positive acid-fast bacilli. Because of the lack of effect of drug therapy on pleural lesions, surgical treatment was performed. The visceral pleura was found adherent fibrously to parietal pleura, which was easily separated by hand. However, at the site of lesions, the adhesion was so tight that extrapleural resection was needed. Because lung tissue and tumor were connected tightly, the lung had to be partially resected. Most content of tumors were caseous necrosis. Although main lesion was located outside of the lung, intrapulmonary invasion was also noticed. Double lesions of this kind of disease seem to be very rare. There is no evidence of relapse until eight months after surgery.     

Case report: chronic aggressive pulmonary sarcoidosis with bilateral cavitation]

A 34-year-old male patient was admitted to our hospital because of progressive exertional dyspnea and weight loss (8 kg in one year). Twelve years previously, he had had an episode of uveitis accompanied with bilateral hilar lymphadenopathy. Scalene node biopsy at that time revealed non-caseating epithelioid granulomas. Four years later, a follow-up chest radiograph showed bilateral fine nodular lesions. The bilateral parenchymal lesions gradually increased in density, and eventually, formed a confluent air-space consolidation containing multi-ocular cavities. On physical examination, the patient was emaciated (Ht 165 cm, Wt 40 kg). Nodular cutaneous lesions were present on his face and elbows. Hypoxemia with hypercapnea (PaO2 56 Torr, PaCO2 51 Torr) was noted. Repeated sputum cultures yielded negative results for acid-fast bacilli, fungi, and other pathological organisms. A transbronchial lung biopsy specimen obtained from near the cavitary lesion revealed non-caseating granulomas compatible with sarcoidosis. Skin lesion biopsy showed similar findings. The cavitation, was therefore considered to be due to ischemic necrosis of confluent sarcoid granulomas. Prednisolone (40 mg daily) was given with a prompt improvement of symptoms including dyspnea, as well as the radiographic abnormalities. We conclude that uncomplicated pulmonary sarcoidosis may rarely develop into an aggressive parenchymal disease with cavitation. It is of importance to differentiate such cases from infectious diseases (tuberculosis, mycosis etc.) because of the need for corticosteroid treatment.     

Sarcoidosis associated with lupus pernio and acute pulmonary cavitation]

Lupus pernio, an uncommon skin condition due to sarcoidosis in Japan, is a chronically persistent, violaceous skin lesion primarily involving the nose, cheek, ears, and fingers. It has often been associated with chronic fibrotic non-resolving pulmonary sarcoidosis. We reported a case of sarcoidosis associated with lupus pernio and primary pulmonary cavitation as a rare manifestation in the lung. A 44-year-old man visited our hospital in January 1986 because of a 3-year history of swollen and violaceous cheeks (lupus pernio) and an 8-year history of erythema in both upper and lower limbs. The biopsy specimen obtained from the skin lesion revealed epithelioid cell granulomas without any evidence of Mycobacterium or fungal growth. Serum ACE (45.4 U/ml) was elevated. Chest X-ray films and computed tomographic (CT) scans showed bilateral hilar lymphadenopathy, nodules, multiple small opacities, and reticulo-linear opacities. Gallium scintigraphy demonstrated abnormal uptake in the mediastinal and hilar lymph nodes and lung fields. The patient had not received corticosteroids. Chest X-ray films and CT scans in July 1989 showed increased opacities and cavitation. Because pyogenic bacteria and acid-fast bacilli were not detected by repeated sputum examinations or bronchial washing, we concluded that the cavitary lesions were manifestations of primary pulmonary cavitation due to sarcoidosis. Prednisolone (40 mg daily) was prescribed and the dosage was gradually tapered. The lung lesions gradually resolved and have not recurred.     

A case of pleural tuberculoma with intra-pulmonary invasion during anti-tuberculosis therapy

A 27-year-old woman who had been treated for pulmonary tuberculosis with anti-tuberculosis drugs for three months was admitted to our hospital because of pain in the chest and back. Chest CT showed improvement in the pulmonary tuberculosis lesions in the right middle lobe and S8, but there was a large pleural mass in the right lower lung field. Histopathological findings of the percutaneous biopsy showed epithelioid cell granulomas that were negative for acid-fast bacilli. We diagnosed the mass as pleural tuberculoma with intrapulmonary invasion. The pleural tuberculoma improved without any additional therapy.     

Case of pubic tuberculous osteomyelitis and pericarditis during anti-tuberculosis chemotherapy

56 year-old man was referred to the department of orthopedics in our hospital for further investigation on right inguinal pain. The patient was initially diagnosed as bacterial myelitis in right pubic bone and was treated with antibiotics. Since his symptom did not improve, the curettage was performed. Histological examination of the pubic bone obtained during the operation showed epithelioid cell granulomas with caseous necrosis, supporting the diagnosis of tuberculous osteomyelitis. Chest X-ray film revealed small nodular lesions in both upper lung fields. Sputum was positive for acid-fast bacilli and Amplified Mycobacterium Tuberculosis Direct Test (TB-MTD) was positive. The diagnosis of pubic tuberculous osteitis and pulmonary tuberculosis was confirmed. Specimens from the pubic bone and sputum were both culture positive for Mycobacterium tuberculosis, and bacilli were sensitive to anti-tuberculosis drugs. The antituberculosis chemotherapy was started with INH, RFP, SM and PZA. Symptoms had gradually improved, however 3 months after starting treatment, high fever developed and chest X-ray revealed heart enlargement and bilateral pleural effusion. Pericardial effusion showed exudative nature with lymphocyte predominancy and high level of ADA, 98.4 U/l. Pleural effusion was transudate. TB-MTD and culture were negative both in pericardial and pleural effusion. Paradoxical reaction was thought to be the cause of pericarditis. TB chemotherapy was continued and pericardial drainage was performed. One month later, fever improved, and pleural effusion and pericardial effusion disappeared. Transient elevated transaminase was observed, and was thought to be the side effect of anti TB drugs. All symptoms gradually improved, and he was discharged after 6 months TB chemotherapy.     

A case of pleural sarcoidosis in which vats lung biopsy, obtained pleural and pulmonary lesions]

Here we report a case that was diagnosed as sarcoidosis but required differential diagnosis from pneumoconiosis. A 51-year-old asymptomatic man, who showed signs of bilateral hilar lymphadenopathy (BHL) on a chest X-ray taken during a medical check, was given a diagnosis of sarcoidosis, based on the results of mediastinoscopic mediastinal lymph node biopsy. Because of the presence of large and small nodular lesions adjacent to the pleura extending from the bilateral upper lobes into the lung field, and continuous bead-like, small nodular lesions in the right interlobar pleura, pleural sarcoidosis was suspected and thoracoscopy was performed. Macroscopically, multiple grayish-white nodules with distinct margins, up to 1cm in diameter surrounded by a proliferation of capillaries were found in the pleura, particularly in the upper lobes. Lesions were also scattered over the interlobar pleura and diaphragmatic surface. Histopathologically, several non-caseous epithelioid cell granulomas and silicotic nodule-like lesions of hyaline degeneration were found; therefore, pneumoconiosis, or more specifically chronic berylliosis, was suspected. Despite these symptoms, the patient did not have a history of exposure, and the results of the lymphocyte stimulation test using beryllium were negative in blood and bronchoalveolar lavage fluid. The patient was given a diagnosis of pleural sarcoidosis and has been observed without treatment.     

A case of primary pulmonary cavitation with thin smooth walls in sarcoidosis]

A 27-year-old female was admitted to our hospital after a regular medical check revealed BHL and cavitation in the right upper lung field on a chest radiograph. Ga scintigraphy showed abnormal uptake bilaterally in the mediastinal and hilar lymph nodes. We strongly suspected lung sarcoidosis, then performed TBLB and BAL. BAL fluid disclosed a high proportion of lymphocytes with a marked elevation of the CD4/CD8 ratio, compatible with sarcoidosis. A TBLB specimen revealed non-caseating epithelioid cell granuloma compatible with a diagnosis of lung sarcoidosis. From the clinical and radiological observations, it was concluded that the cavitation in the present case was primary pulmonary cavitation in sarcoidosis, as distinct from infection, malignancy, bulla or cystic bronchiectasis. Chest radiographs taken a half year after diagnosis showed reduction of the cavitary lesion and disappearance of BHL.     

A case of pulmonary eosinophilic granuloma with involvement of the ocular fundus]

A 37-year-old man was admitted to our hospital because of abnormal shadows on chest X-ray film at routine medical examination. The chest X-ray showed diffuse granular shadows in the bilateral upper and middle lung fields. Chest CT showed multiple cystic lesions and nodular lesions. Bronchoalveolar lavage (BAL) and transbronchial lung biopsy (TBLB) were performed. Electron microscopic examination of BAL fluid revealed Langerhans' cells, and lung tissue specimen obtained by TBLB showed granuloma with infiltration of histiocytes and eosinophils. During the clinical course, the patient complained of cough and decrease of right visual acuity in association with an increase of abnormal shadows on chest X-ray. The lung disease gradually resolved after the cessation of smoking in spite of no therapy. In the right eye, an exudative lesion with retinal elevation was noted in the ocular fundus. Corticosteroid administration was effective for the treatment of this lesion. There was no pathological evidence of the right ocular lesion. However, the correlation of its clinical course with the lung disease suggests a relationship between the ocular lesion and pulmonary eosinophilic granuloma.     

Tsukamurella tyrosinosolvens cultured from sputum of a patient who received total gastrectomy for gastric cancer

A 79-year old woman underwent total gastrectomy under the diagnosis of gastric cancer in Feb. 2003. In the beginning of Jan. 2005, she noticed hemosputum and was admitted to our hospital. Chest radiograph and CT disclosed bilateral upper lobe-dominant nodular opacities in the subpleural areas and ground-glass opacities in right S6. Transbronchial lung biopsy was performed, but no useful information for the diagnosis was obtained. Ziehl-Neelsen stain was negative for the smear of the sputum at admission, but weakly stained acid-fast bacilli were grown in the MGIT culture. By the analysis of mycolic acid and menaquinone of the cell membrane, the bacilli were identified as Tsukamurella. Since she was asymptomatic and repeated sputum examination revealed negative bacilli, she has been observed at the outpatient clinic without any treatment.     

A case of pulmonary sarcoidosis with cavitation]

A 37-year-old woman, who had first been given a diagnosis of sarcoidosis at 23 years of age, was admitted to our hospital after her condition deteriorated. Chest radiographs and CT scan films showed multiple cavitary lesions with thick walls, diffuse granular shadows and bilateral hilar and mediastinal lymphadenopathy. Skin lesions were also observed. In the bronchoalveolar lavage fluid, no pyogenic bacteria, fungi, acid-fast bacilli or malignant cells were detected. A CT-guided transcutaneus lung biopsy specimen revealed a sarcoid granuloma, and we concluded that the cavitary lesions were due to sarcoidosis. After treatment with prednisolone (30 mg/day), the multiple cavitary lesions, diffuse granular shadows and skin lesions showed obvious improvement.     

Multiple osteomyelitis due to Mycobacterium avium with no pulmonary presentation in a patient of sarcoidosis.

A 31-year-old man with multiple osteomyelitis due to Mycobacterium avium is reported. The patient had been on prednisolone for systemic lymphadenopathy which was thought to be caused by sarcoidosis. In June 1990, he noticed high fever and general bone pain. He was found to have multiple lytic lesions in the bones which were biopsied showing acid-fast bacilli. This organism was revealed to be M. avium. The chest radiograph film revealed no abnormal pulmonary findings. Multiple bone lesions in the absence of pulmonary disease is reported to be rare for atypical mycobacterial infection.     

Primary lung cancer (adenocarcinoma) associated with cardiac sarcoidosis]

A 56-year-old woman who had been given oral prednisolone for iridocyclitis by an ophthalmologist received a diagnosis of pulmonary sarcoidosis on the basis of transbronchial lung biopsy findings, and began receiving therapy at our hospital on an outpatient basis. Chest X-ray films disclosed hilar lymphadenopathy in both lungs. In addition, Holter electrocardiograms detected ventricular premature beat (Lown 4B) and echocardiograms detected reduced left ventricular wall motion with dilatation of the left ventricular chamber. Cardiac sarcoidosis developed in the patient. She was admitted to our hospital because of shortness of breath on exertion. Chest X-ray films on admission disclosed a large nodular heterogeneous mass in the right upper lobe. Histologically, transbronchial lung biopsy specimens of the mass disclosed an adenocarcinoma. Although lung cancer and sarcoidosis are common, their coexistence in the same patient is not. Furthermore, the coexistence of lung cancer with cardiac sarcoidosis, as in this case, is very rare.     

A case of pulmonary Mycobacterium shimoidei infection

A 68 year-old male who was ex-smoker presented with fever and cough. Chest radiograph showed infiltrative shadows in both upper lung fields. A sputum smear for acid-fast bacilli was positive. But the isolate was not identified by polymerase chain reaction method. Acid-fast bacilli were cultured from sputum, but the identification was not done by DNA-DNA hybridization method. Mycobacterium shimoidei was identified by 16S ribosomal RNA sequencing with 98.42% matching. Rifampicin, ethambutol, clarithromycin, pyrazinamide, and ciprofloxacin were administered, and the symptom and abnormal shadows on chest radiography improved. And three months later from the initiation of treatment, sputum smear for acid-fast bacilli became negative. Chest CT scan four months after treatments showed decrease of infiltrative shadows. We had treated him for six months, and after that no recurrence occurred.     

Case of pulmonary Mycobacterium mageritense infection: the difficulty of differential diagnosis of granulomatous lung diseases

A 36 year-old female was pointed out of pulmonary abnormal shadows in the annual chest survey. Chest radiograph and computed tomography (CT) disclosed bilateral diffuse infiltrative shadows and tree-in-bud appearance in the right upper lung field and the left lingula. A sputum smear for acid-fast bacilli was negative. Histopathologically, the transbronchial lung biopsy specimen revealed non-caseous epithelioid granulomas with numerous giant cells. Acid-fast bacilli were cultured from her sputum, however, nontuberculous mycobacteria was not detected by DNA-DNA hybridization method. Mycobacterium mageritense was identified by 16S ribosomal RNA sequencing with 100% matching. The isolated colony of M. mageritense was resistant to nine anti-tuberculous drugs. Follow-up chest CT scan showed a gradual decrease of infiltrative shadows without therapy. To the best of our knowledge, M. mageritense infections are rare, and this is the first case report of pulmonary infection in the literature. We conclude that the pulmonary infection of M. mageritense is one of causes of granuloma formation, and in some case it is difficult to differentiate clinically from sarcoidosis.     

A case of miliary tuberculosis associated with acute respiratory failure during pregnancy

A case of miliary tuberculosis associated with acute respiratory failure during pregnancy was reported. A 39-year-old, 29-week pregnant woman was admitted to our hospital with complaints of nonproductive cough and fever on June 12. On admission, her temperature was 38.2 degrees C; pulse rate was 90/min., and blood pressure was 120/76 mmHg. Physical examination revealed moist rales at right lung basis. Chest X-ray showed small nodular infiltrates in right lower lung field. Laboratory data revealed positive CRP, accelerated ESR and increased level of alpha 2-globulin. The number of T-cells was markedly decreased (14/mm3). The PPD skin test was negative, and the sputum smears for acid-fast bacilli were negative. Suspected of bacterial or viral pneumonia, the patient was treated with antibiotics (CPM, EM and CAZ), which had no effects for her. On June 16, the Chest X-ray showed infiltrates throughout bilateral lung fields, and the patient became increasingly dyspneic. On June 18, the results of arterial blood gas, analysis under room air were: PaO2 26.7 Torr, PaCO2 29.0 Torr, pH 7.505. Because of severe hypoxemia, she was intubated and placed on a volume-cycled respirator. Hydrocortisone (1000 mg, daily) was added to treatment because ARDS was suspected. Since the smears of tracheobronchial secretions showed acid-fast bacilli on June 24, she was diagnosed to have miliary tuberculosis. Then the intensive therapy with antituberculosis drugs (isoniazid 400 mg, rifampicin 450 mg, and streptomycin 1g, daily) was started. The non specific antibiotics were discontinued; hydrocortisone was tapered and stopped. The next week, she became afebrile and hypoxemia steadily improved.(ABSTRACT TRUNCATED AT 250 WORDS)     

A case of Beh?et disease with multiple nodular shadows and aneurysm of the brachiocephalic trunk caused by necrotizing vasculitis]

A 36-year-old man was admitted to our hospital in 1994 because of fever, and abdominal CT showed multiple low-density areas in the liver. Although granulomas were found in a liver biopsy specimen, a definitive diagnosis could not be established. With complaints of oral and genital ulcerations and erythema nodosum, Beh?et disease was diagnosed in 1995 and he was treated with colchicine and cyclosporin. In May 1997 he had fever, leg edema, and proteinuria, and a renal biopsy revealed secondary amyloidosis. Cavitary lesions were found on a chest X-ray for the first time, but these later disappeared spontaneously. In October 2002, nodular shadows, cavitary lesions, and a mediastinal tumor appeared on a chest X-ray film. The nodular shadows in the lung fields had transformed into cavity lesions, resulting in the disappearance of the shadows. Specimens obtained from an open lung biopsy showed necrotizing granulomas and destructive vasculitis of the lung, and aneurysm of the brachiocephalic trunk caused by destructive vasculitis. Because multiple nodular shadows with cavitary lesions in Beh?et disease, as in this case, have never been reported, we think this is a rare case.