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We describe a fatal case of diffuse alveolar hemorrhage (DAH) complicated by rheumatoid arthritis (RA). A female patient was diagnosed with RA two months earlier and was treated with prednisolone and tacrolimus due to abnormalities in chest images. The patient was admitted to Hamanomachi Hospital for exertional dyspnea and was treated for exacerbation of chronic heart failure. Even after treatment for heart failure, exertional dyspnea remained. Chest CT imaging revealed contractile, patchy consolidations and ground-glass opacities (GGO) with a peribronchial distribution, suggesting an organizing pneumonia (OP) pattern. She was then treated with an additional 25 mg/day of prednisolone following a clinical diagnosis of OP. When the prednisolone dose was tapered, chest imaging showed worsening infiltration. A bronchoscopy was conducted, and bronchoalveolar lavage fluid was sanguineous, indicating DAH. Given that additional workup for the other etiology of DAH was negative, DAH was thought to be related to RA. Intensive treatment, including pulse dose methylprednisolone, failed to halt progression of respiratory failure, leading to a fatal outcome. The clinical presentation proved challenging due to its rarity. DAH might be a differential diagnosis in RA patients with consolidations and GGO in chest CT images. We review past cases of RA-associated DAH and assess potential treatment choices for future cases.

We describe three cases of acute exacerbation of interstitial lung diseases (ILDs) in which patients were treated with pulsed-doses of corticosteroids followed by nintedanib and maintenance doses of corticosteroids. All cases responded well to pulsed-dose corticosteroids. However, in conventional practice, corticosteroids can complicate adverse events, including opportunistic infections, diabetes, and osteoporosis. One of the cases reported here involved dermatomyositis-associated ILD with anti-EJ antibodies. Considering possible side effects of corticosteroids and the frequent recurrence of ILDs associated with anti-EJ antibodies, we decided to use nintedanib as a sequential treatment for acute exacerbation of ILDs. Nintedanib has just been approved for treatment of progressive fibrosing ILD, but to date, few reports of acute exacerbation of ILDs treated with nintedanib have been published. This case series may contribute to a more thorough discussion regarding the use and timing of nintedanib in treating acute exacerbation of ILDs.

We describe a case of an 82-year-old Japanese woman with pulmonary amyloidosis and hemosiderosis associated with multiple myeloma. She had a background of end-stage renal failure of unknown etiology and had been on maintenance dialysis for 2 years. She complained of exertional dyspnea for four months. High-resolution CT of the chest revealed diffuse ground-glass opacities with mosaic attenuation, consolidation in the left lingular lobe, and wedge-shaped, subpleural nodules in the bilateral lower lobes. A transbronchial lung biopsy of the left lingular lobe showed deposition of amorphous, eosinophilic amyloid at the smooth muscle layer of bronchial tissue, with a positive Congo red staining signal in polarized light. Bronchoalveolar lavage fluid was brownish-yellow, and numerous hemosiderin-laden macrophages were detected with Berlin blue staining. From these findings, a diagnosis of pulmonary amyloidosis complicated with pulmonary hemosiderosis was made. Further work-up led to a diagnosis of multiple myeloma. Pulmonary amyloidosis complicated with pulmonary hemosiderosis is a rare disorder and may be underdiagnosed. Physical examination, such as the appearance of the tongue, can assist the diagnosis of systemic amyloidosis. Use of bronchoscopy allows physicians make an early diagnosis of pulmonary amyloidosis that is minimally invasive.

We describe a Case of a 74-year-old Japanese man with poorly differentiated carcinoma of the anterior mediastinum. The patient underwent anterior mediastinal tumor resection through median sternotomy. The tumor, 7.0 × 5.0 cm, had invaded surrounding tissues (pericardium, right lung, right and left brachiocephalic veins, and superior vena cava). Complete resection of the tumor was not performed. One month after the operation, the patient developed multiple pulmonary metastases, right pleural dissemination, and carcinomatous pleurisy. He was treated with lenvatinib, a novel multi-kinase inhibitor, to which the metastasis responded favorably. This case reports for the first time the clinical usefulness of lenvatinib for poorly differentiated carcinoma of the anterior mediastinum. Management of side effects by several methods, including suspending use of medication on weekends (called a weekends-off strategy), is another strong argument to continue lenvatinib administration.

We describe a case of fulminant onset, rapidly progressive-interstitial lung disease (RP-ILD) with anti-ARS antibodies (anti-PL-7). The patient was successfully treated with nintedanib in addition to intensive immunosuppressive therapies, including intravenous cyclophosphamide. Nintedanib has just been approved for treatment of progressive fibrosing ILD, but to date, no reports of RP-ILD treated with nintedanib have been published. This case report may advance discussions regarding the use and timing of nintedanib in treating RP-ILD.

We report the case of a 50-year-old man with allergic bronchopulmonary mycosis (ABPM) complicated with bilateral septic arthritis of the knees caused by Methicillin-resistant Staphylococcus aureus (MRSA). He had a background of bronchial asthma and end-stage renal failure on maintenance dialysis. He was treated with 30 mg/day of prednisolone for 14 days for ABPM. He developed bilateral septic arthritis of the knees, caused by MRSA during prednisolone treatment. He underwent bilateral arthroscopic washout with a 2-week course of intra-articular arbekacin, concomitantly treated with a 6-week course of intravenous teicoplanin and oral rifampicin, subsequently followed by oral linezolid treatment. However, he suffered exacerbation of ABPM during treatment of septic arthritis. Because of these serious infectious complications, he was treated with mepolizumab instead of corticosteroids for the ABPM, which resolved all symptoms and clinical features. This case highlights mepolizumab treatment as an alternative to corticosteroid therapy for treatment of ABPM in patients with comorbidities such as infection.

We describe a Case of a 74-year-old Japanese man with poorly differentiated carcinoma of the anterior mediastinum. The patient underwent anterior mediastinal tumor resection through median sternotomy. The tumor, 7.0 × 5.0 cm, had invaded surrounding tissues (pericardium, right lung, right and left brachiocephalic veins, and superior vena cava). Complete resection of the tumor was not performed. One month after the operation, the patient developed multiple pulmonary metastases, right pleural dissemination, and carcinomatous pleurisy. He was treated with lenvatinib, a novel multi-kinase inhibitor, to which the metastasis responded favorably. This case reports for the first time the clinical usefulness of lenvatinib for poorly differentiated carcinoma of the anterior mediastinum. Management of side effects by several methods, including suspending use of medication on weekends (called a weekends-off strategy), is another strong argument to continue lenvatinib administration. [ABSTRACT FROM AUTHOR]

We describe a case of an 82-year-old Japanese woman with pulmonary amyloidosis and hemosiderosis associated with multiple myeloma. She had a background of end-stage renal failure of unknown etiology and had been on maintenance dialysis for 2 years. She complained of exertional dyspnea for four months. High-resolution CT of the chest revealed diffuse ground-glass opacities with mosaic attenuation, consolidation in the left lingular lobe, and wedge-shaped, subpleural nodules in the bilateral lower lobes. A transbronchial lung biopsy of the left lingular lobe showed deposition of amorphous, eosinophilic amyloid at the smooth muscle layer of bronchial tissue, with a positive Congo red staining signal in polarized light. Bronchoalveolar lavage fluid was brownish-yellow, and numerous hemosiderin-laden macrophages were detected with Berlin blue staining. From these findings, a diagnosis of pulmonary amyloidosis complicated with pulmonary hemosiderosis was made. Further work-up led to a diagnosis of multiple myeloma. Pulmonary amyloidosis complicated with pulmonary hemosiderosis is a rare disorder and may be underdiagnosed. Physical examination, such as the appearance of the tongue, can assist the diagnosis of systemic amyloidosis. Use of bronchoscopy allows physicians make an early diagnosis of pulmonary amyloidosis that is minimally invasive. • Pulmonary amyloidosis can present nodules, GGOs, and consolidations. • Pulmonary amyloidosis can be complicated with pulmonary hemosiderosis. • Pulmonary amyloidosis can be diagnosed using bronchoscopy. • Physical examination of the tongue can assist diagnosis of systemic amyloidosis. [ABSTRACT FROM AUTHOR]

We describe three cases of acute exacerbation of interstitial lung diseases (ILDs) in which patients were treated with pulsed-doses of corticosteroids followed by nintedanib and maintenance doses of corticosteroids. All cases responded well to pulsed-dose corticosteroids. However, in conventional practice, corticosteroids can complicate adverse events, including opportunistic infections, diabetes, and osteoporosis. One of the cases reported here involved dermatomyositis-associated ILD with anti-EJ antibodies. Considering possible side effects of corticosteroids and the frequent recurrence of ILDs associated with anti-EJ antibodies, we decided to use nintedanib as a sequential treatment for acute exacerbation of ILDs. Nintedanib has just been approved for treatment of progressive fibrosing ILD, but to date, few reports of acute exacerbation of ILDs treated with nintedanib have been published. This case series may contribute to a more thorough discussion regarding the use and timing of nintedanib in treating acute exacerbation of ILDs. [ABSTRACT FROM AUTHOR]

We describe a fatal case of diffuse alveolar hemorrhage (DAH) complicated by rheumatoid arthritis (RA). A female patient was diagnosed with RA two months earlier and was treated with prednisolone and tacrolimus due to abnormalities in chest images. The patient was admitted to Hamanomachi Hospital for exertional dyspnea and was treated for exacerbation of chronic heart failure. Even after treatment for heart failure, exertional dyspnea remained. Chest CT imaging revealed contractile, patchy consolidations and ground-glass opacities (GGO) with a peribronchial distribution, suggesting an organizing pneumonia (OP) pattern. She was then treated with an additional 25 mg/day of prednisolone following a clinical diagnosis of OP. When the prednisolone dose was tapered, chest imaging showed worsening infiltration. A bronchoscopy was conducted, and bronchoalveolar lavage fluid was sanguineous, indicating DAH. Given that additional workup for the other etiology of DAH was negative, DAH was thought to be related to RA. Intensive treatment, including pulse dose methylprednisolone, failed to halt progression of respiratory failure, leading to a fatal outcome. The clinical presentation proved challenging due to its rarity. DAH might be a differential diagnosis in RA patients with consolidations and GGO in chest CT images. We review past cases of RA-associated DAH and assess potential treatment choices for future cases. [ABSTRACT FROM AUTHOR]