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Background: Endobronchial aspergillosis is still an insufficiently recognized concept., Patients and Methods: Ten patients who did not have obvious predisposing factors and parenchymal fungal infection were analyzed. They were confirmed to have endobronchial Aspergillus by histology and culture, and were classified according to the presence of bronchiectasis, allergic reaction, and asthmatic symptom., Results: Bronchiectasis was detected in all 10 patients, IgE elevation (>370 IU/ml) in 7, Aspergillus specific IgE-RAST in 8, eosinophilia in 7, and asthmatic symptom in 5. Cases were classified into allergic bronchopulmonary aspergillosis (ABPA) (5 cases), ABPA not fulfilling Rosenberg's criteria (2 cases), and endobronchial aspergilloma (3 cases)., Conclusion: We proposed classifying endobronchial aspergillosis without obvious systemic predisposing factors into "ABPA", "ABPA without asthma", "ABPA-S (seropositive)", and "Endobronchial aspergilloma". A fifth subtype of endobronchial aspergillosis containing "saprophyte" is warranted.

A 65-year-old woman whose parents were from Okinawa Prefecture, had productive cough and bilateral diffuse nodular lesions on chest X-ray. She had been shown a human T-cell lymphotropic virus type-1 (HTLV-1) carrier. Video-assisted thoracoscopic lung biopsy showed marked peribronchiolar infiltration of lymphocytes and stenosis of bronchioles. HTLV-1 associated bronchiolo-alveolar disorder (HABA) was diagnosed. The symptoms, hypoxemia and chest X-ray findings improved with oral erythromycin. However, expiratory chest CT showing mosaic perfusion, pulmonary function test demonstrating increased thoracic gas volume, and ventilation scintigraphy resulting in decreased clearance during 8 years, all of those findings indicated progression of air trapping. Abnormalities on chest CT partially improved, but bronchiolar lesions have deteriorated. Expiratory chest CT, body phlethysmography and ventilation scintigraphy were recommended to clarify the course of HABA.

We report a case of bird-related chronic hypersensitivity pneuminitis exhibiting the fluctuation of serum markers for interstitial lung disease along with the changes in life environment. A 65-year-old man had had an abnormal chest radiograph for 2 years and had complained of a non-productive cough. He had had 30 parakeets 20 years previously and had used feather products for 15 years. In autumn and early winter wild birds had visited persimmons trees in the neighboring garden. Antibodies to bird-related antigens in the broncho-alveolar lavage fluids and sera were positive and the thoracoscopic lung biopsy specimens histologically revealed airway-centered fibrosis. We then determined he was having bird-related chronic hypersensitivity pneumonitis. After avoidance of feather products, all of serum SP-A, SP-D and KL-6 decreased. But three markers elevated and radiographic findings worsened accompanied with the increase of visiting wild birds in next autumn. After pruning persimmon trees and starting corticosteroid with cyclosporine, disease activity gradually improved.

Metastasis of testicular germ cell tumor should be included in the differential diagnosis when young male patient have multiple pulmonary metastases. However burned-out tumors cannot be easily detected on inspection and palpation of the testis. A 19 year-old man visited to our hospital complaining of anorexia, weight loss and dyspnea. Chest X-ray films showed multiple lung nodules. Physical examination revealed gynecomastia, and many cervical, axillary, and inguinal lymph nodes with a diameter of 1 cm were palpable. Physical examination of testis revealed no laterality. Multi-detector CT showed multiple lung nodules, a hepatic and a retroperitoneal large mass and a tiny calcification in the right testis. Histological findings of the lung obtained by percutaneous biopsy and the presence of a calcification in the testis led to a diagnosis of testicular choriocarcinoma showing burned-out tumor. However there was no previous report of burned-out tumor detected by CT, MD-CT including that of the testis was valuable at the first diagnostic stage when germ cell tumor was suspected.

A 29-year-old woman was admitted because of chest radiograph abnormality. She had no respiratory complaints. Chest CT demonstrated an ill-defined nodule of 20mm with the "sarcoid galaxy sign" in the right upper lobe. Transbronchial biopsy (TBB) specimens from right S2 revealed non-caseating epithelioid cell granuloma. Initial clinical findings suggested mycobacterial infection. However, while waiting for the results of mycobacterial cultures in bronchial washing fluid, the tuberculin skin reaction was found to be negative, and enlargement of nodule, mediastinal lymphadenopathy and elevated soluble IL-2R were observed. Cultures for mycobacterium were negative and repeat TBB specimens revealed granulomatous inflammation. We diagnosed with sarcoidosis based on these findings. Solitary nodular sarcoidosis is rare with only 17 cases having been reported. These cases were diagnosed with difficulty because of non-specific clinical findings and of the 17, 16 cases (94%) were diagnosed by surgical procedures. We observed the clinico-radiological course of solitary nodules and the change in tuberculin reaction. Although a negative tuberculin skin reaction was commonly recognized in sarcoidosis patients, we confirmed that initial positive tuberculin reaction changed to negative according to disease progress. To the best of our knowledge, this is the first case report in adults.

A 63-year-old woman complained of continuous dry cough and high fever for two months. Chest radiography showed no abnormality, but inspiratory fine crackles were audible. Interstitial lung disease was suspected and bronchoalveolar lavage was performed via a bronchoscope. Disseminated minute granular lesions with redness and hypervascularity from the upper trachea to bilateral lober bronchi were detected. Lesions were also present in the membranous portion of the left main bronchus. Histological results for bronchial biopsy and transbronchial lung biopsy showed non-caseous epithelioid cell granuloma. This, together with a high CD4/8 lymphocyte ratio (4.11) in bronchoalveolar lavage fluid and the gallium scintigraphic findings, confirmed the diagnosis of sarcoidosis. To the best of our knowledge there are no other reports of cases with a similar bronchoscopic appearance in which the chest roentgenologic classification was stage 0, despite severe respiratory symptoms. Nodular lesions are seen in some cases of endobronchial sarcoidosis, but in this case, these widespread granular lesions were a unique feature that prompted us to make this report.

Case. A 54-year old woman was found to have an abnormal shadow in a regular checkup chest X-ray film. We suspected a bronchial artery aneurysm based on a contrast-enhanced chest CT. Aortography, bronchial arteriography and pulmonary arteriography showed a bronchial artery aneurysm, 2 cm in diameter, connecting the right bronchial artery, inferior phrenic artery, and pulmonary artery. Bronchoscopy revealed dilatation and hypervascularity of moniliform submucosal vessels below the right truncus intermedius. She underwent bronchial artery embolization several times, but new feeding vessels developed each time. We considered this case required surgical resection. Bronchoscopy after aneurysmectomy revealed decrease of moniliform submucosal vessels. Histological examination revealed a three-layer structure leading to both the pulmonary and bronchial arteries. Conclusion. We diagnosed idiopathic bronchial artery aneurysm connecting to a pulmonary artery.

A 64-year-old woman was admitted with a chest radiograph abnormality. She had no compliant and the results of her physical examination were normal. A chest radiograph showed a 25-mm area of patchy opacity in the left upper lung field. Chest CT demonstrated a finger-like opacity along the left B3a and c that was highly suggestive of mucoid impaction of the bronchi. Bronchofiberscopy revealed mucous plugs in left B3, in which the filariform fungul hyphae were detected by Grocott stain. Rosenberg's clinical criteria have been cited frequently for the diagnosis of allergic bronchopulmonary aspergillosis (ABPA). On the one hand his criteria have historical significance, but at the same time various problems have been pointed out. Although the patient was not given a diagnosis of ABPA based on Rosenberg's criteria, she was given it based on the presence of type I immunologic response, mucoid plugs, hyphae of Aspergillus, central bronchiectasis. She had localized opacity only along a segmental bronchus. Our report may provide valuable information on the course of ABPA.

It is not well understood what kind of histologic resolution is obtained with corticosteroid medication in sarcoidosis, or how we are able to judge cure in that disease. We examined the cases of sarcoidosis who were under steroid medication and received lobectomy and lymphadenectomy for combined lung cancer. Steroid treatment had been introduced for the relief of visual disturbance, not for the pulmonary lesion. Administration of corticosteroid improves clinical, laboratory, bronchoalveolar lavage and radiological findings, but it is difficult to make histological granulomatous inflammation completely disappear. Improvement of radiological and clinical problems in sarcoidosis is not the same as complete cure in patients with steroid-treated sarcoidosis.

Chest CT detected a small localized ground glass opacity in the right upper lung in a 52-year-old woman being treated for nocardiosis. A PAS-stain positive material and elevated surfactant level were confirmed in bronchoalveolar lavage fluid, then a diagnosis of pulmonary alveolar proteinosis was established. In early pulmonary alveolar proteinosis with focal opacity, HRCT can demonstrate the substantial findings of alveolar proteinosis such as a crazy-paving appearance or geographic distribution. We should note that alveolar proteinosis in the early stage is easily overlooked and, in addition, nocardiosis might overlap with alveolar proteinosis.

We reported an immunocompetent elderly patient with disseminated Mycobacterium avium infection exhibiting bronchial, pulmonary, nodal, otitic and osteitic lesions. An 82-year-old man was initially hospitalized with cervical and mediastinal lymphadenopathy. M. avium was demonstrated in gastric juice and a lymph node. An endobronchial polypoid lesion was formed by perforation of mediastinal mycobacterial lymphadenitis into the right main bronchus. Combined treatment by CAM, RFP, EB, and SM caused the lesions to diminish and the treatment was continued for 18 months. One year after completion of treatment the patient was re-admitted with complaints of left ear pain, and a subcutaneous abscess on his back. M. avium was again demonstrated from external ear exudate and aspirated subcutaneous pus. Re-treatment with combined chemotherapy induced prompt resolution of the ear and bone lesions. It is unusual that immunocompetent patients suffer disseminated non-tuberculous mycobacterial infection, but chest physicians should pay attention to M. avium infection because of its worldwide dissemination.

A 60-year-old man was given a diagnosis of pulmonary and ocular sarcoidosis. His radiological abnormalities and visual disturbance resolved after two years. Ten years later, at age 70, squamous cell carcinoma was detected in the right lower lobe of the lung. Lymphocyte CD4/8 ratio in bronchoalveolar lavage fluid has remained at a high level for the previous 10 years and was 7.41 immediately before the operation. Chest CT and gallium scintigram could not detect abnormalities in mediastinal or hilar nodes. The tumor and right lower lobe were resected with hilar and mediastinal lymph nodes. Histological examination revealed that there were numerous epithelioid cell granulomas in mediastinal and hilar lymph nodes. BALF analysis reflects residual granulomatous inflammation, even if the radiological findings do not show any abnormalities.

A 52-year-old woman was taking 10 mg of prednisolone on alternate days for the treatment of autoimmune hemolytic anemia. She was informed of an abnormality on a chest X-ray film about 3 months previously and was admitted to our hospital with sudden onset of chest pain and fever. On the following day, she underwent transthoracic needle biopsy and the lung lesion was diagnosed as pulmonary nocardiosis. She showed improvement of fever and the lung lesion with administration of an antibacterial agent, but suddenly developed vomiting and headache. Brain MRI revealed multiple brain abscesses at more than 20 sites. A subsequent change of the antibacterial agent achieved control of the lung lesion and brain lesions. This case shows that prednisolone can cause nocardiosis as an opportunistic infection even at a low dose and that antibacterial agents act differently on the lung and brain lesions caused by this organism.

We report a case of pulmonary thromboembolism, in which obstruction of the right subclavian vein, also called Paget-von Schroetter syndrome, was detected. The patient was a 39-year-old man (a scaffold constructor). He lost consciousness at work, and was admitted as an emergency case to our hospital. He had noticed gradually worsening dyspnea for 1 month. Chest radiography showed Westmark's sign in the lungs and enlarged hilar vascular markings on both sides. Pulmonary perfusion scintigraphy confirmed multiple flow defects. Upper and lower limb venography disclosed interruption of the right subclavian vein, leading to a diagnosis of pulmonary thromboembolism secondary to upper limb vein thrombosis. In patients who have pulmonary thromboembolism without an apparent underlying disease, the lifestyle and work habits should be considered and the possibility of subclavian vein thrombosis should be kept in mind.

A 27-year-old man was admitted to hospital for the investigation of hemosputum. He is a serving member of the Japan Self-Defense Forces. Chest radiography showed absence of the right hilar component, and the ipsilateral hemithorax was smaller than that of on the left side. Pulmonary arteriography demonstrated complete absence of the right pulmonary artery. Right cardiac catheterization did not show any concomitant cardio-vascular malformation. Therefore, this case was diagnosed as an isolated absence of the right pulmonary artery. Bronchial arteriograms demonstrated showed vascular enlargement and proliferation of the right bronchial artery. Bronchofiberscopic examination showed obvious bronchial mucosal vascular enlargement with submucosal eruption and swelling of the right bronchi. We also re-examined the chest radiographs of this patient from the previous 9-years. Those revealed a chronological decrease of the right lung volume and an increase of the cardio-thoracic ratio. Isolated absence of the right pulmonary artery is generally considered to have preferable survival, but close observation is necessary to monitor the pulmonary hemodynamics.

A 34-year-old woman who had been keeping five budgerigars in her home was admitted with cough and progressive exertional dyspnea that had continued for three months. Chest CT scan demonstrated diffuse centrilobular nodular opacities throughout both lung fields. Flexible bronchoscopy revealed polypoid lesions with diameters of 2-3 mm located at the right B1/B2 spur. B3a/B3b spur and middle/lower bronchus spur. Their surfaces were glossy and smooth but slightly lobulated. The histological findings were consistent with inflammatory polyps containing lymphoid follicles in a dense infiltrate of lymphocytes. A positive environmental provocation test and precipitating antibodies confirmed the diagnosis of hypersensitivity pneumonitis (HP) caused by budgerigars (bird fanciers' lung). To our knowledge, there is no previous report of HP accompanied with endobronchial polyps, but this rare case shows the involvement of large airways in HP.

We report two cases of Sjören's syndrome (SjS) with infiltrative lung disease showing upper lung field predominance. Case 1 was seen in a 68-year-old woman, who was admitted with dyspnea on exercise. Chest CT scanning demonstrated a central predominance of irregularly shaped consolidation with tractionectasis, distributed along the broncho-vascular bundles in both upper lobes. Case 2 occurred in a 70-year-old woman, who was admitted with cough. Chest CT scan showed a central predominance of irregularly shaped opacities with multiple small cystic structures in both upper lobes. Both cases were shown to be nonspecific interstitial pneumonia (NSIP) by video-assisted thoracoscopic lung biopsy, in which lung involvements were distributed around the bronchovascular sheath with relative sparing of the subpleural region. Although neither case complained of sicca symptoms, decreased saliva production was detected using the Saxon test, and further examinations revealed the presence of primary SjS. Pulmonary involvement in SjS is variable, and distribution along the broncho-bronchioles in the majority of the upper central lung field is a characteristic appearance of SjS lung disease. In patients with such patterns in chest radiography, further diagnostic differentiation should be conducted to confirm or rule out SjS.

A 58-year-old woman was admitted because of bilateral diffuse nodular shadows on chest radiograph. Video-assisted thoracoscopic lung biopsy specimens showed marked lymphocytic infiltration into the bronchiolar wall. HTLV-1 antibody was examined because the patient's parents were born in Okinawa Prefecture. The patient turned out to be an adult T-cell leukemia-lymphoma (ATLL) carrier with positive HTLV-1 antibody. Therefore, HTLV-1 associated bronchiolitis was diagnosed. Although no dry symptoms appeared, it became clear by the saxon test that she was also complicated with Sjögren syndrome. Generally, it is reported that there is coherence with HTLV-1 infection and Sjögren syndrome. So the HTLV-1 infection might have accounted for the pathogenesis of these three disorders (HTLV-1 infection, bronchiolitis, Sjögren syndrome).

We encountered a pair of monozygotic twins with summer-type hypersensitivity pneumonitis. Patients 1 and 2 were 24-year-old men who worked in the same place and shared the same room, which was built of wood. In August, patient 1, a non-smoker, was referred to our hospital because of coughing, fever and dyspnea. In November, the same symptoms appeared in patient 2, who was a smoker. The difference between the onset times in patients 1 and 2 was suspected to be due to cigarette smoking, because their occupations and other circumstances were the same and they were monozygotic twins.

In patients with sarcoidosis, we examined the differences in bronchoalveolar lavage fluid (BALF) findings between a low CD4/8 ratio group (< or = 1: n = 7) and a high CD4/8 ratio group (> or = 4: n = 47). On initial examination, no significant difference in gender, age, serum ACE level, eye lesions, or skin lesions was observed between the two groups, but the rate of negative PPD skin tests was significantly lowered in the low CD4/8 ratio group. No significant difference in initial BALF findings was observed between the two groups. In the low CD4/8 ratio group, the CD4/8 ratio increased significantly after three years from the initial BALF, but not in the high CD4/8 ratio group. The CD4/8 ratio is not associated with the clinical manifestation on first examination, but our data suggest that there may be some differences in clinical manifestations at the first examination and in the changes with time in the BALF findings between two groups. However, a greater accumulation of data is necessary before this can be confirmed.

To review the pulmonary CT findings in sarcoidosis at diagnosis, and to analyze the change in each finding at follow-up in cases without corticosteroid treatment. The study included 21 cases of pulmonary involvement of sarcoidosis. We analyzed the presence or absence and grade of each HRCT finding: bronchial wall thickening, enlargement of vascular shadows, pleural involvement, septal thickening, small nodules, ground-glass opacities, centrilobular opacities, consolidation, nodules, and volume loss. Afterwards, we compared the initial CT with the follow-up CT, and described the change of each finding as "improved" or "not improved". Furthermore, we decided if each case as a whole was improved or not after considering all of the pulmonary CT findings. Twelve of the 21 cases were improved. Small nodules, ground-glass opacities, centrilobular opacities, and nodules had improved in more than 50% of the cases since the initial CT. However, pleural involvement (10/11) and volume loss (6/9) were not improved. Pleural involvement and volume loss correlated the radiological irreversibility (p < 0.05). Of the several pulmonary CT findings in sarcoidosis, pleural involvement and volume loss show the highest rates of irreversible pulmonary changes.

We explored the potential involvement of Sjögren's syndrome as a cause of diffuse lung disease. A prospective clinical study was performed with measurements of saliva production made using the Saxon test. Sixty-seven diffuse lung disease patients who did not exhibit xerosis were examined. The group included 43 patients with sarcoidosis, 11 with interstitial pneumonia, 3 with primary pulmonary lymphoma (PPL), 2 with idiopathic BOOP, 2 with chronic eosinophilic pneumonia, and 6 with other diseases. Decreased saliva production was detected in 11 (16.4%), and Sjögren's syndrome was diagnosed in 4 (6.0%). Lung lesions displayed by the group with Sjögren's syndrome included PPL, bronchiolitis, sarcoidosis, and interstitial pneumonia. We concluded that in patients with diffuse lung diseases, it is always important to discriminate between those with sicca syndrome and Sjögren's syndrome. In our study, the Saxon test proved highly effective as a screening procedure for this purpose.

A 66-year-old woman presented with left chest pain. Left pleural effusion was seen on a chest X-ray film and a large mass disclosed by chest computed tomography. However, the patient refused to undergo a recommended operation. Six months later, she was admitted without any symptoms. A huge (18 cm diameter) mass was detected by magnetic resonance imaging (MRI), and consisted of heterogeneous solid and cystic components. Angiography and endoscopic sonography disclosed a suspected abdominal tumor, which was resected by thoracolaparotomy. Gastric stromal tumor was diagnosed on the basis of histological findings. Chest pain and pleural effusion are rare as initial clinical symptoms of such tumors.