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The serum concentration of procalcitonin (PCT) is specifically elevated in severe bacterial infections. In Japan, PCT has been used as a serum marker for bacterial sepsis since February, 2006. However, the evidence of it in respiratory infectious diseases is limited. In the present study, we analyzed 57 episodes of systemic inflammatory response syndrome in 53 inpatients to investigate the usefulness of serum PCT measurement in respiratory infectious diseases. Although the sensitivity and a negative predictive value in common bacterial infections were low, the specificity and positive predictive value were 95% and 93%, respectively. This suggests that the significance of serum PCT measurement relies on confirming the diagnosis of common bacterial infections. Analysis using a receiver operating characteristic (ROC) curve demonstrated that serum PCT was a more reliable measure of bacterial sepsis than leukocyte counts in the peripheral blood or serum C-reactive protein. In cases of community-acquired pneumonia, except atypical pneumonia, the hospital mortality rate was significantly higher in PCT-positive patients than in PCT-negative patients (38% vs. 0%), indicating that serum PCT could be a factor predicting in-hospital death.

A 54-year-old woman was admitted with general fatigue and dyspnea on exertion. Her serum LDH level was markedly elevated to 2145 IU/L, and chest CT revealed diffuse centrilobular opacities. Total cell counts in bronchoalveolar lavage fluid were elevated, and lymphocytes accounted for 98% of the cells. A transbronchial lung biopsy demonstrated numerous CD20-positive atypical cells in the alveolar capillaries, so intravascular lymphoma (IVL) was diagnosed as having. Lymphoma cells were also present in the bone marrow sinusoids, while there was no sign of hemophagocytosis. Combined chemotherapy (CHOP with rituximab) successfully induced complete remission, and she has been free of recurrence for 40 months. In cases with diffuse centrilobular opacities on chest CT, accompanied by elevated serum LDH, it is important to rule out IVL by performing TBLB.

A 77-year-old woman was referred to our department with hemoptysis. Microscopic polyangiitis (MPA) with resultant alveolar hemorrhage was diagnosed because of diffuse infiltrate of the right lung, proteinurea, renal dysfunction and the presence of MPO-ANCA. The disease responded well to corticosteroid therapy. She was discharged, but as corticosteroid was gradually tapered, an irregularly-shaped nodule appeared in the right upper lung field within 2 weeks. She was re-admitted because the nodule increased in size with cavity formation in spite of the administration of antibacterial agent. Pulmonary aspergillosis was diagnosed, since bronchial washing and transbronchial lung biopsy revealed the presence of Aspergillus fumigatus. Serum beta-D-glucan was decreased and the cavity was reduced in size, responding to the treatment with micafungin. However, she died later of systemic infection by a herpesvirus. We report this case because of the interesting course of pulmonary aspergillosis that subacutely formed a cavity.

A 70-year-old man in whom nodular and reticular shadows had been noted on chest radiography since 1992 was admitted to our hospital with complaints of persistent cough and dyspnea on exertion in August, 2000. The definitive diagnosis of lung abnormalities was not confirmed by TBLB. He was re-admitted to our hospital to undergo a lung biopsy by video-assisted thoracoscopic surgery. Although desquamative interstitial pneumonia was diagnosed, respiratory failure developed rapidly after surgery. He responded well to high-dose steroid administration followed by maintenance therapy with a moderate dose of steroid, resulting in a considerable importance of the clinical condition associated with a significant decrease in the ground-glass opacities and infiltrative shadows. Although we could find no literature reporting acute exacerbation of DIP, our case demonstrates that DIP may also be acutely exacerbated when a severe insult is superimposed.

A 69-year-old man become aware of myiodesopsia. He visited the Department of Ophthalmology at Keio University Hospital and choroidal metastasis of the right eye was diagnosed. A tumor shadow was detected in the lower lobe of the left lung on chest radiographs, and the serum CEA concentration was found to be significantly increased. Through bronchoscopic examinations, he was confirmed to have primary lung cancer (histological classification: adenocarcinoma). Although detailed systemic examinations were performed, no metastasis to lymph nodes or distant organs except the choroid plexus was detected, which is very rare in a case of stage IV primary lung cancer. In conclusion, it is suggested to be very important to look for ophthalmological abnormalities, even in the case of apparently early lung cancer that seems to be resectable.

We describe a case of relapsed small cell lung cancer (SCLC) recognized by a duodenal tumor, its probable metastasis. A 69-year-old man was admitted to Keio University Hospital complaining of persistent sputum production in September, 1996. A diagnosis of SCLC of the left lung invading the mediastinum was based on a transesophageal biopsy. Chemotherapy consisting of CDDP and VP-16 followed by thoracic irradiation at a total dose of 50 Gy was performed from October 1996 to August 1997, resulting in CR (Complete Response) of the tumor. In April of 1999, a mass surrounding the duodenum was found through an abdominal CT survey for tumor relapse, but no other tumors were detected in a series of CT scans or inbone scintigraphy. Subsequent fiberscopy of the upper gastrointestinal tract revealed an ulcerative tumor extensively invading the mucosa of the duodenal bulb. Biopsy specimens obtained from the duodenal tumor showed small-cell carcinoma with features similar to those of SCLC found in 1996, suggesting that SCLC of the left lung metastasized to the duodenal wall. Chemoradiotherapy with 4 cycles of CDDP and VP-16 followed by abdominal irradiation at a dose of 30 Gy was given again from May to September 1999, producing good PR (Partial Response). Although metastasis of SCLC to the duodenum seldom occurs, this report indicates that its early detection and effective treatment may prevent serious symptoms caused by obstruction of the duodenum or the papilla Vater.