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A 31-year-old man visited our hospital with a persistent cough. Computed tomography (CT) scans of his chest showed a very large mass and multiple nodular lesions in the right lung field, mediastinal and hilar lymph node enlargement and splenomegaly. Laboratory analysis showed polyclonal hyperimmunoglobulinemia and increased levels of serum C-reactive protein (14.05 mg/dl) and interleukin-6 (44.2 pg/ml). The pathological findings of lung specimens obtained using video-assisted thoracoscopy revealed hyperplasia of the lymphoid follicles with germinal centers, plasma cell infiltration which stained positively with either anti-kappa chain or anti-lambda chain antibodies, and fibrosis in the alveolar septum. We made a diagnosis of multicentric Castleman disease based on high levels of serum IL-6, multiple lymph node enlargement and splenomegaly, although this case had histological findings in common not only with Castleman disease but also with inflammatory myofibroblastic tumor. His abnormal chest radiography findings and laboratory data significantly improved 6 months after his first visit, without any treatment. Multicentric Castleman disease showing a very large mass is extremely rare.

A 49-year-old woman visited our clinic on July 12th, 2006, complaining of discomfort in fingers of both hands, edema of both lower limbs, and pain in the right shoulder and chest. Chest X-ray examination showed an infiltrative shadow with pleural effusion and loss of lung volume in the left lower lung field. She was treated with CTRX, but it was ineffective, and she was therefore admitted to Kurume University Hospital on July 21st, 2006. Chest CT demonstrated pyothorax and loss of lung volume in the left lung. Culture of a sample obtained by thoracentesis yielded Nocardia asteroides. The pulmonary nocardiosis improved after oral administration of trimethoprim-sulfamethoxazole, and the patient was discharged on August 25th 2006. No immunological impairment was observed, and the serum levels of ACHT and cortisol were normal. In February 2007, however, she developed facial acne, facial edema ("moon" face), centripetal obesity, and weight gain. Cushing syndrome was diagnosed on the basis of tests including a low-dose dexamethasone suppression test. To the best of our knowledge, there has been no previous report of pulmonary nocardiosis with pyothorax in a patient with Cushing syndrome. We assume that the present patient had pre-(sub-) clinical Cushing syndrome when she presented with pulmonary nocardiosis and pyothorax.

In December, 2001, a 67-year-old woman was given a diagnosis of having systemic sclerosis and organizing pneumonia. Steroid treatment improved her condition, and she received no further medication for approximately three years thereafter. In October 2005, she visited Kurume University Hospital because of cough and fever. Chest X-ray film and high-resolution computed tomography (HRCT) showed bilateral patchy consolidation with air-bronchogram sign and ground-glass opacities, predominantly in the right lower lung field, suggesting relapse of organizing pneumonia. However, bronchoalveolar lavage fluid (BALF) analysis showed an increase of neutrophils (79%) and the CD4/CD8 ratio (4.04). Streptococcus dysgalactiae subsp. equisimilis (beta-hemolytic, Lancefield group G) was detected by bacterial culture of the BALF. Treatment with sulbactam sodium/ampicillin sodium (SBT/ ABPC) rapidly improved her symptoms. The patchy consolidations on chest X-ray and HRCT also disappeared after the treatment. On the basis of these clinical and bacteriological findings, we diagnosed the patient as having bacterial pneumonia caused by Streptococcus dysgalactiae subsp. equisimilis.

A 52-year-old woman was admitted to Yame General Hospital because of persistent cough, wheeze, and shortness of breath at age 48. Chest X-ray and computed tomography (CT) showed bilateral centrilobular shadows. Pulmonary function test revealed obstructive dysfunction. She also had chronic sinusitis. Initially, diffuse panbronchiolitis was diagnosed and she was given macrolides, but no improvement was observed. Thus video-assisted thoracoscopic lung biopsy (VATS) was performed in order to establish a definitive diagnosis. Histopathological findings were compatible with a diagnosis of follicular bronchiolitis. Treatment with corticosteroid (oral prednisolone, 50 mg/day) improved her condition. However, on reducing the steroid doze, her symptoms and chest X-ray film/CT findings became exacerbated. In addition, polyarthritis appeared. Further investigations revealed a diagnosis of rheumatoid arthritis. Only 2 cases of follicular bronchiolitis preceding rheumatoid arthritis have been reported in Japan.

A 52-year-old man presented with general fatigue and body weight loss. Chest X-ray and computed tomography showed bilateral, mediastinal and hilar lymphadenopathy. Laboratory tests revealed that peripheral eosinophils (1,850/microL) and serum IgE levels (1,610 U/L) were markedly increased. Cervical lymph node biopsy was performed for a definitive diagnosis. Histopathological analysis, using conventional H&E staining, showed mild infiltration of eosinophils into lymphoid follicules in the cervical lymph node. Immunohistopathological analysis, using an anti-human IgE antibody, showed mesh-like IgE positive staining in lymphoid follicles. These clinical and pathological findings are compatible with a diagnosis of Kimura's disease.

A 51-year-old woman who had been treated for years for rheumatoid arthritis presented with a persistent dry cough and shortness of breath three weeks after administration of the ACE inhibitor temocapril hydrochloride against essential hypertension. Chest radiography and computed tomography showed diffuse reticular shadows and ground-grass opacities in both lung fields. Bronchoalveolar lavage fluid analysis showed an increase of lymphocytes and CD8+ T cells (93.3% of lymphocytes), and a decrease of the CD4/8 ratio of the T cell subset (0.04). Histopathological analysis of trans-bronchial lung biopsy specimens showed infiltration of lymphocytes into the alveolar septa and exudation of alveolar macrophages, signs characteristic of interstitial pneumonia. A drug lymphocyte stimulation test was positive for temocapril, but negative for other drugs. On the basis of these findings, we diagnosed temocapril hydrochloride-induced interstitial pneumonia.