RESUMEN
The skeleton is the most common site for distant metastasis in patients with cancer. To detect bone metastasis and evaluate the efficacy of treatment, we usually use bone scintigraphy and check serum alkaline phosphatase (ALP). However, such evaluation is sometimes difficult due to flare phenomenon. A 61-year-old male was referred to our department with a suspected diagnosis of lung cancer. Following thorough examinations, he was diagnosed with primary lung cancer (adenocarcinoma, Stage IV) and found to have a mutation in the epidermal growth factor receptor gene at exon 21 (L858R). After initiating treatment with oral gefitinib, ALP increased and peaked at 3,592 U/L by 3 weeks and decreased thereafter. At 4 weeks following treatment initiation, bone scintigraphy revealed a marked increase in abnormal accumulation of (99m)Tc-polyphosphate, but the primary tumor and metastases in regions other than the bone were reduced. At 9 weeks after treatment initiation, abnormal accumulations was improved in bone scintigraphy, and computed tomography revealed osteoblastic changes consistent with the accumulated lesion observed by bone scintigraphy. After initiating cancer treatment for bone metastasis, it is not uncommon to observe transient asynchronous accumulation in bone scintigraphy or transient increases in ALP in patients who ultimately respond to the treatment. These changes are called flare phenomenon, and documented in patients with prostate cancer or breast cancer receiving treatment. When determining the efficacy of treatments that target carcinomas with bone metastases, it is important to note that flare phenomenon is often indistinguishable from disease progression indicators.
Asunto(s)
Adenocarcinoma/patología , Fosfatasa Alcalina/sangre , Antineoplásicos/uso terapéutico , Neoplasias Óseas/secundario , Huesos/química , Neoplasias Pulmonares/patología , Polifosfatos/análisis , Compuestos de Tecnecio/análisis , Adenocarcinoma/tratamiento farmacológico , Adenocarcinoma del Pulmón , Neoplasias Óseas/tratamiento farmacológico , Gefitinib , Humanos , Neoplasias Pulmonares/tratamiento farmacológico , Masculino , Persona de Mediana Edad , Quinazolinas/uso terapéutico , Cintigrafía/métodos , Tomografía Computarizada por Rayos X , Resultado del TratamientoRESUMEN
A 78-year-old Japanese woman was admitted to our hospital for fever, dry cough, and right pleural effusion. She was diagnosed with mantle cell lymphoma (MCL) at 73 years of age and was treated with carcinostatics, but MCL was refractory. Chest computed tomography (CT) on admission revealed a localized trabecular shadow in the middle lobe of the right lung and right pleural effusion with thickened visceral pleura. Right pleural effusion was exudative, lymphocytes were dominant, and adenosine deaminase isoenzymes were elevated. (18)F-fluorodeoxyglucose positron emission tomography/CT revealed positive findings in the right thickened visceral pleura and right middle lobe. We suspected tuberculosis, but bronchoscopy revealed that the washing fluid was negative for Ziehl-Neelsen staining. Thoracoscopy under local anesthesia revealed redness on the parietal and visceral pleura and fibrin network. Pathological findings from pleural biopsy included granulomas, Langhans-type giant cells, and diffuse invasion of lymphocytes with atypical nuclei. Immunophenotypes were CD5(+), CD10(-), CD19(+), CD20(+), λ(+), CD25(+) by flow cytometry and CD20(+), CD45RO(-), cyclin D1(+), bcl2(+), bcl6(-) by immunohistochemistry. We diagnosed MCL involvement of the pleura, and highly suspected tuberculous pleurisy. The patient received antituberculosis therapy with rifampicin, isoniazid, pyrazinamide, and ethambutol. After 4 weeks, culture of bronchoscopy washing fluid was positive for Mycobacterium tuberculosis. We diagnosed pulmonary tuberculosis. Patients with malignant lymphoma are vulnerable to tuberculosis. In addition to diagnosing MCL involvement of the pleura, it is important to consider the possibility of complication with tuberculosis.
Asunto(s)
Linfoma de Células del Manto/complicaciones , Mycobacterium tuberculosis/aislamiento & purificación , Pleura/patología , Tuberculosis Pleural/complicaciones , Tuberculosis Pulmonar/complicaciones , Adenosina Desaminasa , Anciano , Femenino , Humanos , Linfoma de Células del Manto/patología , Imagen Multimodal , Derrame Pleural/patología , Tomografía de Emisión de Positrones , Toracoscopía , Tomografía Computarizada por Rayos X , Tuberculosis Pleural/patología , Tuberculosis Pulmonar/patologíaRESUMEN
We report a case of a 41-year-old woman admitted to our hospital for dyspnea on exertion and nonproductive cough. High-resolution computed tomography (HRCT) revealed central ground-glass opacities surrounded by ring-shaped areas of consolidation (reversed halo sign), predominantly in the lower lobes. Bronchoalveolar lavage fluid revealed an increase of the total number of cells (35 x 10(4)/ml), including elevated lymphocyte level (69%) and decreased CD4/CD8 ratio (0.45). Histopathological examination by transbronchial lung biopsy showed polypoid masses of granulation tissue filling the lumens of a respiratory bronchiole and alveolar ducts, consistent with organizing pneumonia. After admission the patient complained of dry eyes and dry mouth. The serum anti-SS-A antibody level was also elevated (65.0 U/ml). Labial salivary gland biopsy specimens revealed focal lymphocytic infiltration of more than 50 per 4 mm(2). There were no findings of rheumatoid arthritis or other collagen diseases. We diagnosed primary Sjögren syndrome with secondary organizing pneumonia with a reversed halo sign. She was treated with prednisolone (0.5 mg/kg body weight, 35 mg/day). After treatment, the chest CT showed improvement through consolidation.
Asunto(s)
Neumonía/diagnóstico por imagen , Neumonía/etiología , Síndrome de Sjögren/complicaciones , Adulto , Femenino , Humanos , Pulmón/diagnóstico por imagen , Síndrome de Sjögren/diagnóstico , Tomografía Computarizada por Rayos XRESUMEN
An 81-year-old woman was admitted to our hospital for hyponatremia and impaired consciousness after unsuccessful antibiotic treatment for pneumonia-like symptoms by a previous doctor. A chest X-ray film revealed unilateral infiltration. Mycobacterium tuberculosis was detected on a sputum smear and pulmonary tuberculosis was diagnosed. Based on the diagnostic criteria, we believed that her hyponatremia a consequence of syndrome of inappropriate antidiuretic hormone secretion (SIADH) as a complication of pulmonary tuberculosis. Sodium loading and water restriction quickly improved her serum sodium level and impaired consciousness. Anti-tuberculosis therapy reduced the abnormal shadows noted on chest X-ray films, and the sputum smear became negative for Mycobacterium tuberculosis. Her serum sodium level remained normal after the discontinuation of sodium loading. Previous reports have associated SIADH with severe types of tuberculosis such as miliary tuberculosis, tuberculosis meningitis, and pulmonary tuberculosis with massive bacterial excretion. However, this complication can also occur in mild tuberculosis, as in this case, thus SIADH should also be considered in mild cases of tuberculosis.
Asunto(s)
Síndrome de Secreción Inadecuada de ADH/etiología , Tuberculosis Pulmonar/complicaciones , Anciano de 80 o más Años , Trastornos de la Conciencia/etiología , Femenino , Humanos , Síndrome de Secreción Inadecuada de ADH/complicacionesRESUMEN
Paradoxical reaction in tuberculosis treatment is not generally fatal. On rare occasion it can lead a patient with diminished lung function and poor general condition to death. A 60-year-old man with history of left upper lobe resection from tuberculosis was referred to our hospital due to the recurrence of tuberculosis. Sputum examination showed a positive smear with a Gaffky score of 10, and the chest X-ray and CT revealed pulmonary infiltrate with many cavities (bII2) on the whole left lung field. Anti-tuberculosis drugs (isoniazid, rifampicin, ethambutol and pyrazinamide) were administered, but his high fever persisted, and the infiltrate on the chest X-ray deteriorated. While the positive sputum smear persisted, the culture became negative after one month. The tuberculous bacilli were susceptible to all anti-tuberculosis drugs in vitro. Though we performed examinations and trial treatments for non-tuberculous conditions such as pneumonia and drug-induced pneumonia, the patient died after 6 months. A necropsy specimen taken from the worsening lesion (the right upper lobe) as shown on the chest X-ray revealed many epithelioid granulomas. The patient had malnutrition, diabetes, alcoholic hepatic disorder, and insanity. It is supposed that although antituberculosis drugs were effective, a large quantity of killed organisms was continuously excreted from many cavities in the left lung toward the right lung. Lesions in the right lung thus newly produced in this paradoxical reaction seemed to reduce the remaining lung function. In addition, poorly controlled diabetes caused deteriorated heart function. These multiple factors contributed to the poor prognosis of the patient and his ultimate death.
Asunto(s)
Tuberculosis Pulmonar/fisiopatología , Insuficiencia Cardíaca/etiología , Humanos , Masculino , Persona de Mediana Edad , Insuficiencia Respiratoria/etiología , Tuberculosis Pulmonar/complicaciones , Tuberculosis Pulmonar/tratamiento farmacológicoRESUMEN
Patient 1 was a 54-year-old woman who was admitted with high-grade fever. Abnormal laboratory findings included hypoxemia, and elevated levels of LDH and soluble interleukin-2 receptor (sIL-2R). Chest computed tomography scans (CT) revealed diffuse ground-glass shadows in both lungs. Transbronchial lung biopsy (TBLB) confirmed the diagnosis of intravascular lymphomatosis (IVL). Patient 2 was a 46-year-old man who was also admitted with high-grade fever. Abnormal laboratory findings included slight hypoxemia, and elevated levels of LDH and sIL-2R. Chest CT images revealed diffuse, fine nodular densities in both lungs and several small nodules in the bilateral lower lobes. Perfusion scintigraphy revealed multiple defects in both lungs. TBLB specimens yielded a diagnosis of IVL. Although antemortem diagnosis of IVL is frequently difficult, it is necessary to perform TBLB in those patients who show fever not responding to antibiotics, elevated levels of LDH and sIL-2R, and hypoxemia.
Asunto(s)
Biopsia/métodos , Pulmón/patología , Linfoma de Células B/patología , Neoplasias Vasculares/patología , Bronquios , Femenino , Humanos , Masculino , Persona de Mediana EdadRESUMEN
A 85-year-old man who had a past history of gastrectomy but no subsequent chemotherapy was suffering fever and fatigue. The infiltrative shadow with cavitation on his chest X-ray film did not improve despite treatment with several antibiotics after admission. Transcutaneous needle aspiration performed for diagnosis of the cavitated lung lesion yielded Streptomyces. A definitive diagnosis of streptomyces lung infection was established. We believed that this is the first case of streptomyces infection of the lung reported in Japan. The current case was also rare because he did not have any immunosuppressive status, while almost all cases previously reported.
Asunto(s)
Neumonía Bacteriana/microbiología , Streptomyces/aislamiento & purificación , Anciano de 80 o más Años , Humanos , MasculinoRESUMEN
An 87-year-old female was being examined by her primary care doctor during a follow-up of 4 to 5 years after a diagnosis of non-tuberculous mycobacterial infection. An exacerbation of a shadow was suspected on a chest X-ray film, and therefore the patient was referred to our hospital. Her chief clinical symptom was mild occasional coughing, but no clearly abnormal findings were observed on the clinical examination. On chest CT, a cystic lesion was detected in the right posterodorsal side of the trachea at the level of the thoracic aperture, resulting in the diagnosis of a right paratracheal air cyst. Right paratracheal air cyst is a relatively rare disease, but it is believed that such a diagnosis can be made easily based on its localization and the CT findings, and it is a disease to which attention should be paid, which is why we are reporting it.
Asunto(s)
Quistes/diagnóstico por imagen , Tomografía Computarizada por Rayos X , Anciano de 80 o más Años , Femenino , Humanos , TráqueaRESUMEN
We present a case of pulmonary sarcoidosis showing the "reversed halo sign" on high-resolution computed tomography (HRCT). A 27-year-old man presented with nonproductive cough and high fever lasting for 3 weeks. A chest radiograph showed multiple areas of consolidation and cavitary shadows in the lungs. The HRCT showed the reversed halo sign, a central ground-glass opacity surrounded by crescent or ring-shaped areas of consolidation. Moreover, miliary nodules were observed in the central ground-glass opacity areas and around the outer areas of consolidation. The HRCT also showed a large nodule, subpleural nodules bordering the costal pleural surfaces, and interlobular fissure. Transbronchial biopsy was performed, and the histopathologic features were those of sarcoidosis and without cryptogenic organizing pneumonia.
Asunto(s)
Sarcoidosis Pulmonar/diagnóstico por imagen , Tomografía Computarizada por Rayos X/métodos , Adulto , Biopsia , Diagnóstico Diferencial , Humanos , MasculinoRESUMEN
PURPOSE: To evaluate the treatment outcome of patients with pulmonary tuberculosis before and after the induction of DOT. METHODS: A retrospective study of the outcome of 239 tuberculosis patients treated during January 1996 to June 2003. We reviewed clinical charts collected on all patients with positive cultures for Mycobacterium tuberculosis. The patients of non-DOT group had received a traditional unsupervised drug regimen, before we have undertaken DOT. The patients of DOT group received therapy under direct observation by nurses. We compared sputum smear conversion period, sputum culture conversion period, duration of admission and treatment, recurrence rate, treatment success (cure and completion of treatment) rate and incidence of adverse effects between DOT and non-DOT group. RESULTS: Sputum conversion period and incidence of adverse effects were not significantly different between both groups. The duration of admission and treatment of DOT group was significantly shorter than those of non-DOT group. Rate of relapse and treatment success was not different between two groups. Over-80-year-old patients treated by DOT revealed a higher culture conversion rate after 2-month treatment than those who were not treated with DOT. CONCLUSION: We could not prove the usefulness of DOT during hospitalization for tuberculosis patients from the points of treatment success rate and relapse rate.
Asunto(s)
Terapia por Observación Directa , Tuberculosis Pulmonar/tratamiento farmacológico , Anciano , Anciano de 80 o más Años , Femenino , Humanos , Pacientes Internos , Masculino , Resultado del TratamientoRESUMEN
A 74-year-old woman had general fatigue and mild fever in August 2004. Her chest X-ray showed slight ground glass opacities in the upper and middle lung fields of both lungs. Though she was prescribed antibacterial drugs, the abnormal shadows on chest X-ray did not improve. The chest CT showed ground glass opacities and reticular shadows with thickened alveolar septa (crazy-paving appearance) in both lungs, and a clearly defined mass in the anterior mediastinum. She underwent thymo-thymectomy with wedge resection of the upper lobe of the left lung. Anterior mediastinum tumor was pathologically diagnosed as thymoma. Lung biopsy demonstrated alveoli filled with SP-A positive granular materials, and we diagnosed pulmonary alveolar proteinosis. About 1 month after operation, the shadows on chest CT showed improvement. We think there might be some relationship between thymoma and pulmonary alveolar proteinosis.