A case of pneumonitis due to sho-saiko-to

We reported a case of pneumonitis due to Sho-saiko-to. A 71-year-old woman was admitted to our hospital because of pneumonia. She complained of dry cough, pyrexia and severe dyspnea. Fine crepitation was heard on physical examination of the chest and a chest X-ray film revealed diffuse reticulo-nodular shadow in both lung fields. We suspected summer-type hypersensitivity pneumonitis and followed her up, however her condition deteriorated. Under a suspicion of drug-induced pneumonitis, all drugs were stopped and she was given prednisolone. Consequently her complaints, laboratory data and chest X-ray findings markedly improved. Microscopic examination of a transbronchial lung biopsy specimens showed interstitial pneumonitis. The results of a lymphocyte stimulation test were positive for sho-saiko-to. She gave informed consent after receiving an explanation of the challenge test. She was tested with 2.5 g sho-saiko-to twice and developed high fever and dyspnea with hypoxia, while the chest X-ray film also revealed diffuse infiltrative shadows similar that on admission. Based on these findings, we diagnosed this case as pneumonitis due to sho-saiko-to. To our knowledge, there has been no previous case of pulmonary hypersensitivity due to sho-saiko-to reported in the world.     

A case of diphenylhydantoin-induced pneumonitis]

A 60-year-old man had been administered diphenylhydantoin (DPH) for prevention of convulsive seizures following clipping of an aneurysm of the middle cerebral artery. About one month after the commencement of DPH administration, he developed cough and low grade fever. He was treated with various antibiotics, but his condition increasingly worsened. Chest X-ray film revealed bilateral interstitial processes throughout the entire lung fields. Transbronchial lung biopsy was performed and the obtained specimen showed histological findings compatible with drug-induced pneumonitis. Administration of DPH was stopped immediately and 50 mg/day of prednisolone was started. The patient's condition rapidly improved, and the abnormal shadows on chest X-ray film gradually diminished. The lymphocyte stimulation test by DPH was positive with a stimulation index of 282%.     

Williams-Campbell syndrome complicated by multiple meniscus signs in an adult case; is it a characteristic finding?

A 49-year-old woman visited our hospital for further examination of abnormal lung shadows in September 1984. She had suffered from pneumonia at the age of 3 years and had been treated for bronchial asthma until the age of 15. Many thin-wall cystic shadows were seen on her chest X-ray film in 1983. In July 1984, a mass-like lesion with a meniscus sign appeared in one of the cystic shadows. The number and the size of similar lesions increased with worsening of productive cough. An infiltrative shadow was recognized in the left lower lobe in September 1987 and January 1988, but was resolved by treatment by ofloxacin. Frequent bacterial examinations of sputum and bronchial secretions revealed numerous Pseudomonas aeruginosa but no fungi. Serum antibody to Aspergillus fumigatus was negative and antifungal therapy was not effective. Bronchography showed many cystic dilated bronchi, which ballooned during inspiration and collapsed with expiration. The peripheral bronchi seemed to be normal. These findings along with her clinical course led us to make a diagnosis of Williams-Campbell syndrome. The mass-like shadows were considered to have arisen from viscid secretions that were rendered round by the characteristic movement of the ectatic bronchi.     

A case of pneumonitis due to serrapeptase

A case of pneumonitis due to Serrapeptase was described. A 69-year-old man was treated with Serrapeptase for 16 days because of common cold, then fever, nonproductive cough and dyspnea developed and chest X-ray revealed diffuse fine granular shadows in bilateral lung fields. Once the administration of Serrapeptase was halted, symptoms, chest X-ray abnormalities and laboratory data improved markedly. The fraction of lymphocytes increased in bronchoalveolar lavage fluid and OKT4/T8 decreased. Microscopic examination of transbronchial lung biopsy showed interstitial pneumonia. Both leukocyte migration inhibition test and sensitized hemagglutination test were positive for Serrapeptase. Based on these findings, we diagnosed this case as Serrapeptase-induced pneumonitis.     

Wegener's granulomatosis in a woman with asymptomatic primary biliary cirrhosis

A 60-year-old woman was admitted to our hospital in June 1985, complaining of fever, cough and right lower chest pain, with a five-year history of asymptomatic primary biliary cirrhosis. Chest X-ray on admission showed an infiltrative shadow in the right lower lung field. She was first treated with various antibiotics unsuccessfully. Hemoptysis continued. Dyspnea and anemia appeared. Chest X-ray 17 days after admission showed multiple infiltrative shadows in the both lung fields. She was treated with steroid pulse therapy successfully. During prednisolone treatment decreasing nodular shadows with cavities appeared on chest X-ray. An open lung biopsy was performed in March 1986. The histologic findings showed a necrotizing vasculitis with granuloma and perivascular fibrosis. She was treated with prednisolone and prednisolone-azathioprine therapy unsuccessfully, but successfully with prednisolone-cyclophosphamide therapy. This case was a rare case of Wegener's granulomatosis with transition from fulminant type to granulomatous type. No similar case of Wegener's granulomatosis with asymptomatic primary biliary cirrhosis has been reported in the literature.     

A case of severe summer-type hypersensitivity pneumonitis treated with high-dose administration of steroid]

A 40-year-old man who lived in a wooden house built 30 years ago presented with complaints of fever, dry cough and dyspnea. Chest X-ray findings showed interstitial shadows throughout bilateral lung fields. After admission, high-dose administration of 3000 mg of methylprednisolone was performed because of deterioration of chest X-ray shadows and symptoms. In a week, clinical data and symptoms improved. Findings of BAL fluid on admission revealed a relative increase of lymphocytes, neutrophils and mast cells, and pathological findings of transbronchial lung biopsy revealed non-caseous granulation and alveolitis. Precipitating antibodies and indirect fluorescent antibodies against Trichosporon cutaneum and Cryptococcus neoformans had positive reactions and T. cutaneum was isolated and identified from the patient's house. A diagnosis of summer-type hypersensitivity pneumonitis was made according to the criteria advocated by Ando et al. This seemed to be a rare case of summer-type hypersensitivity pneumonitis prolonged after isolation from his normal living environment, successfully treated by high-dose administration of steroid.     

A case of Sweet's syndrome with a variety of chest radiological findings]

We report a rare case of Sweet's syndrome (acute febrile neutrophilic dermatosis) with a variety of chest radiological findings. A 73-year-old man, who had been treated with corticosteroid for Sweet's syndrome for 2 years, was admitted to our hospital because of pyrexia with a infiltrative chest shadow. Chest CT scans showed consolidation and ground-glass opacities with air-bronchogram in the right lower lobe. Treatment with antibiotics seemed to be effective but there was no improvement of chest shadows. Simultaneously with his pyrexia, diffuse centrilobular-micronodular shadows and a mass-like shadow appeared on chest CT after 2 months and after the next 2 months, respectively. Bronchoalveolar lavage fluid contained increased neutrophils but not any infectious pathogen. Transbronchial lung biopsy specimens revealed chronic interstitial infiltrate with alveolar wall thickening and neutrophil accumulation in the airspace. A diagnosis of pulmonary involvement in a patient with Sweet's syndrome was finally made and he was successfully treated with corticosteroid.     

A case of rapidly progressing pulmonary aspergillosis presenting various forms of shadow]

A 66-year-old woman who had a history of bullous pemphigoid was admitted to our hospital with abnormal shadows on chest radiography. She was being treated with prednisolone, which suggested that she might be in an immunosuppressed state. The chest radiograph and CT scan disclosed an infiltrative opacity, rapidly progressive cavitation, subsequent mycetoma formation, and a nodular shadow with a clear margin. Histological examination revealed a fungus ball in the cavitary lesion and a small mass of hyphae in necrotic tissue. After transbronchoscopic infusion of fluconazole, the cavitary lesion showed a marked resolution on the chest CT scan, and the infiltrative shadow and the nodule disappeared. It is said that aspergillosis is a spectrum of conditions whose precise manifestation is determined by the state of the lung tissue and by the patient's immune status. We report this rare case of pulmonary aspergillosis presenting various forms of shadow.     

A case of smoldering adult T-cell leukemia complicated by various pulmonary infections]

A 46-year-old man was admitted to Oita Medical College Hospital on October 16, 1987, because of cough and sputum. Chest X-ray and chest CT films showed diffuse reticulonodular shadow. The specimens obtained by transbronchial lung biopsy revealed cysts of pneumocystis carinii. Abnormal lymphocytes with lobulated nuclei were found 2-7% of peripheral leucocytes. The anti HTLV-I antibody was positive. According to these data, we diagnosed the patient as smoldering adult T cell leukemia with pneumocystis carinii pneumonia. The abnormal shadow on chest X-ray disappeared after SMX-TMP and pentamidine treatment. After about 1 year, he was again admitted for high fever. Chest X-ray showed infiltration with cavity in right upper lobe. Streptococcus pneumoniae was isolated from the sputum. The infiltration shadow on chest X-ray disappeared after antibiotics treatment. However, multiple nodular shadow appeared on the chest X-ray and ATL cell infiltration was found in the specimens of transbronchial lung biopsy. ATL cells in peripheral blood also increased and serum LDH and Calcium levels were markedly high. According to these data, we diagnosed the patient as having a ATL crisis. Although chemotherapy for ATL was started, the ATL, cell infiltration shadow on the chest X-ray enlarged, and bilateral diffuse patchy shadows was appeared on the chest X-ray. He died of respiratory failure on April 26, 1989. Cytomegalovirus pneumonia and ATL cell infiltration were revealed by necropsy.     

A case of steroid-resistant acute hypersensitivity pneumonitis successfully treated with an immunosuppressive drug]

A 28-year-old man complaining of cough and fever was hospitalized because of bilateral diffuse granular lung shadows. Hypersensitivity pneumonitis was diagnosed based on bronchoalveolar lavage fluid (BALF) and transbronchial lung biopsy (TBLB). Since antigen avoidance alone was not effective, steroid pulse therapy was started, and his symptoms and chest X-ray findings improved. After discharge, he moved to another residence. A few weeks later, fever and dyspnea recurred, then he was hospitalized on the suspicion of acute exacerbation of hypersensitivity pneumonitis. Steroid therapy resulted in no improvement on this occasion. Lung biopsy under video-assisted thoracoscopy was performed, and acute hypersensitivity pneumonitis was diagnosed pathologically. Although steroid therapy was continued, hypoxia still remained and a KL-6 level markedly increased. Combined therapy with steroid and cyclosporin A was started, and his symptoms, physical findings, laboratory data, and chest X-ray findings gradually improved. There has been no report in which cyclosporin A was used for acute hypersensitivity pneumonitis but this case indicates that cyclosporin A is efficacious for its treatment.     

A case of bromocriptine-induced interstitial pneumonitis in an iron factory worker exposed to sand dust

A 62-year-old male, was admitted on Oct. 7, 1987 because of productive cough and dyspnea. He worked for an iron factory, where pneumoconiosis was regarded as an occupational disease, for 40 years. No abnormal finding had been noted on his mass screening chest roentgenograms. He was well until three years ago when hypertension and Parkinsonism were noted. Since then he was treated with beta blockers, L-DOPA, amantadine and bromocriptine. Two weeks before admission, he suddenly complained of dyspnea and productive cough. His chest roentgenograms showed diffuse reticulonodular infiltration in both lung fields. The partial pressure of oxygen of the arterial blood was 65.9 Torr. The first transbronchial lung biopsy obtained from right B8 on Sept. 29, 1987 (before the admission) revealed some epithelioid granulomas and the second biopsy obtained from right B10 on Oct. 14, 1987 demonstrated bronchiolar edema and infiltration of inflammatory cells. Fibrotic changes associated with carbon dust between airways and vessels were also noted. Lymphocyte stimulation index by bromocriptine was 362%, and that by amantadine, 139%, L-DOPA, 150%, respectively. After ceasing the administration of bromocriptine, productive cough, dyspnea and the reticulonodular shadows diminished gradually. These findings strongly suggest that the interstitial pulmonary lesions are bromocriptine-induced interstitial pneumonitis. His occupational exposure to inorganic dust may be a predisposing factor.     

A case of lung infection due to Mycobacterium abscessus]

We report a case of lung infection due to Mycobacterium abscessus (M. abscessus). A 60 year-old woman was admitted to our hospital because of an abnormal shadow found on chest radiography and a bloody sputum. Chest radiography revealed infiltrative and linear shadows in the middle and lower fields of both lungs. The sputum smears were negative for acid-fast bacilli, but sputum culture was positive. Rapidly growing mycobacteria were detected. The patient was treated with clarithromycin. Since M. abscessus was identified from repeated cultures of the sputa, the patient was treated with Imipenem/Cilastatin and Amikacin for four weeks, during which the chest radiography improved. After discharge, the treatment with clarithromycin and minocycline was continued for ten months, and the chest radiography improved further. Our treatment for M. abscessus may be a useful choice for drug treatment of such cases.     

A case of chronic necrotizing pulmonary aspergillosis]

A 70-year-old woman with diabetes mellitus who was following a therapeutic diet showed an infiltrative shadow in the right upper lung field on chest roentgenogram in April, 1986. She was diagnosed as having pneumonia and was treated for five months with several antibiotics, but the abnormal shadow on chest roentgenograms increased in size. Therefore, she was admitted to our hospital in October 1986. Although tubercle bacilli were not isolated from her sputum or from materials obtained by bronchoscopic examination, we made an initial diagnosis of pulmonary tuberculosis based on the findings of chest roentgenograms, tomographs and CT scanning. In spite of treatment with antituberculous drugs, the infiltrative shadow with cavity on chest roentgenograms continued to increase in size, and the patient developed occasional hemoptysis. Percutaneous needle biopsy was performed in February 1987 to establish a definite diagnosis, and the presence of Aspergillus fumigatus was confirmed by microscopic examination and culture. After treatment with miconazole and 5-FC for 3 to 4 months, the abnormal shadow on the chest roentgenogram gradually disappeared and was almost undetectable one year later. The clinical course of this patient was considered to be strongly indicative of chronic necrotizing pulmonary aspergillosis, which was described by Binder et al. in 1982.     

A case of Beh?et's disease with hemoptysis and chest X-ray abnormality

A 41-year-old man was admitted to our hospital because of hemoptysis and dyspnea. Physical examination disclosed oral ulcer, acne and scrotal ulcer. Although ocular lesions were absent, the needle reaction was positive. Then we diagnosed this case as incomplete type of Beh?et's disease. Chest X-ray showed diffuse retinolinear shadows in the entire lung field and an infiltrative shadow in the left middle lung field. CT-scan revealed interstitial shadows in the entire lung field, a wedge-shaped shadow in left S6 and aneurysmic dilatation of the left lower lobe pulmonary artery. Pulmonary angiography showed obstruction and aneurysmic dilatation of the left lower lobe pulmonary artery. Pathological examination of the TBLB specimen revealed thickening of the vessel wall, perivascular infiltrations of mononuclear cells, hemorrhage and slight thickening of alveolar septae. These findings were compatible with pulmonary lesions of Beh?et's disease. After administration of corticosteroid, the symptoms and the chest roentgenographic findings improved. Pulmonary lesions of Beh?et's disease were discussed.     

A case of plasma cell granuloma with good response to steroid therapy

A 46-year-old man was admitted with complaints of fever, cough and anterior chest pain. Chest X-ray examination disclosed an infiltrative shadow in the right upper lung field and chest CT scan strongly suggested invasion of mediastinum and anterior chest wall. Therefore, steroid therapy was selected because biopsy specimen showed proliferation of fibroblasts and mononuclear cells mainly containing plasma cells with no evidence of malignancy. After steroid therapy, chest X-ray examination showed that the infiltrative shadow was greatly reduced. However, since infiltrative shadow was increased again at 3 years after the initiation of steroid therapy, right upper lobectomy was performed. Histopathological analysis of resected tumor demonstrated proliferation of mature plasma cells and fibroblasts in conjunction with minor infiltration of neutrophils and lymphocytes. At 18 months after operation, new shadows appeared in right S8 and S10 which were shown to have almost the same histological findings as the resected tumor. Steroid therapy was restarted, and then the size of shadows decreased. It is conceivable that steroid therapy is an effective therapy for pulmonary plasma cell granuloma, especially multifocal and relapsing cases.     

A case of flomoxef-induced pneumonitis]

We report a case of flomoxef-induced pneumonitis. A 22-year-old man was treated with flomoxef following liver biopsy. A few days later he developed a high fever and severe dyspnea, and his chest X-ray film revealed diffuse reticulo-nodular shadows in both lung fields. We suspected interstitial pneumonitis due to flomoxef, and pulse therapy with methylprednisolone was started. He showed rapid recovery of symptoms and marked regression of pulmonary infiltration in his chest X-ray. Lymphocyte stimulation test was positive to flomoxef, which was compatible with the diagnosis of drug-induced pneumonitis. To our knowledge, there has been no previous case of pulmonary hypersensitivity to flomoxef reported in Japan.     

Drug-induced interstitial pneumonia associated with inhalation of fibrinolysin-deoxyribonuclease (ElaseR)]

A 73-year-old man was referred to our department because of sputum production and fever. He had under-gone a total laryngectomy for laryngeal cancer. His chest radiograph showed patchy ground-glass shadows in both lung fields. He was treated with antibiotics for pneumonia, but his symptoms continued, and the size of the patchy shadows in the chest radiograph increased. Inhalation therapy with ElaseR had been started from one day before fever arose. Withdrawal of ElaseR treatment resolved his symptoms. We therefore suspected drug-induced interstitial pneumonia. Transbronchial lung biopsy specimens showed infiltration of lymphocytes in the alveolar septa and thickening of those septa. A bronchoalveolar lavage revealed an increased number of lymphocytes, and the CD4/CD8 ratio was 0.3. A drug lymphocyte stimulation test (DLST) with peripheral blood lymphocytes was strongly positive (S.I. 2127%) for ElaseR. The anti-nuclear antigen (ANA) was detected (x640), and the anti-single strand DNA antibody titer was also high (123.4 IU/ml). About 10 weeks after the withdrawal of ElaseR, the infiltrative shadows and the abnormal laboratory findings improved spontaneously. On the basis of these findings, we arrived at a diagnosis of drug-induced interstitial pneumonia associated with inhalation of ElaseR.     

A case of intravascular large cell lymphoma with pulmonary invasion]

A 60-year-old man was admitted to our hospital because of dyspnea, cough, and fever two weeks after participating demolition work. Computed tomography of the chest showed multiple diffuse interstitial shadows. While fibrotic bronchoscopy and transbronchial lung biopsy showed alveolitis. We diagnosed hypersensitivity pneumonitis (HP) and treated with mPSL-pulse therapy then got better soon, and also chest abnormal shadow disappeared. Two month later he was admitted because of the same symptom. His chest CT-scans showed diffuse interstitial shadows and we diagnosed recurrence of HP. Treatment with mPSL pulse-therapy was not effective. Acute respiratory failure appeared and progressed daily. The patient died 3 weeks after admission. The final diagnosis of autopsy is angiotrophic large cell lymphoma, a very rare type of lymphoma (<1% of NHL). It is important to consider angiotrophic large cell lymphoma in the differential diagnosis of diffuse interstitial lung disease.     

A case of pneumonia caused by Mycobacterium avium complex successfully treated with clarithromycin

We reported on a 79-year-old woman with pneumonia caused by Mycobacterium avium complex (MAC). She was admitted with fever, general fatigue, and cough. A chest X-ray film showed infiltrative shadows in the right lung field. In spite of administration of conventional antibiotics, the infiltrative shadows enlarged. A chest CT scan revealed areas of consolidation and ground glass opacities. Bronchoalveolar lavage (BAL) examination revealed an increased number of lymphocytes. Transbronchial lung biopsy revealed many granulomatous regions with giant cells. Mycobacterium intracellulare was found in the culture of BAL fluid and identified by PCR. Treatment was started with rifampicin, ethambutol, and clarithromycin. However, rifampicin and ethambutol were soon discontinued because of severe anorexia. Her symptoms and the radiographic appearance markedly improved following treatment of clarithromycin alone. Subsequently small doses of rifampicin and ethambutol were restarted because her general condition was much improved. These findings suggest that clarithromycin is an effective and tolerable agent for elderly patients with MAC.     

A case of isoniazid (INH)-induced pneumonitis]

A 58-year-old man was referred for the evaluation of a lung nodule on chest X-ray. On admission, chest X-ray showed a solitary nodule with cavitation in the left lung field. Histological examination revealed epithelioid cell granulomas and the diagnosis of pulmonary tuberculosis was made. He was treated with INH, ethambutol (EB), and rifampicin (RFP). On the 16th day of treatment, he developed dry cough and high fever. On the 20th day, dyspnea developed and PaO2 was decreased to 38.2 Torr. Chest X-ray showed new widespread infiltrates in both lung fields and bilateral pleural effusions. The size of the cavitary lesion was decreased. Transbronchial biopsy specimen showed slight interstitial thickening, lymphocyte infiltration, and multiple granulomas. Drug lymphocyte stimulation test was positive only with INH (230%). INH-induced pneumonitis was highly suspected. All drugs was discontinued and hydrocortisone 2400 mg daily was started. He soon became afebrile, and dyspnea and dry cough resolved. Chest X-ray film showed resolution of infiltrative shadows. He was subsequently successfully treated with streptomycin, EB, and RFP without any adverse effects. To our knowledge, this is the sixth reported case of INH-induced pneumonitis.