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Background: Dyspnea and desaturation during exercise are essential assessment items for pulmonary rehabilitation. Characterizing patients using these 2 factors may be important for providing more effective pulmonary rehabilitation. This study aimed to categorize subjects with interstitial lung disease (ILD) using dyspnea and desaturation at the end of the 6-min walk test (6MWT)., Methods: This was a retrospective study including 230 stable subjects with ILD who underwent 6MWT in our out-patient department at a general hospital in Japan. The modified Borg scale and oxygen saturation determined by S pO 2 at the end of the 6MWT were used for cluster analysis using the k -means method with k = 4., Results: Subjects were classified into 4 characteristic clusters. S pO 2 at the end of the 6MWT was lower in cluster 4 (80.5 ± 3.0%) than in clusters 1 (94.3 ± 2.0%), 2 (94.3 ± 1.9%), and 3 (87.9 ± 1.8%) and was lower in cluster 3 than in clusters 1 and 2. The modified Borg scale score at the end of the 6MWT was higher in clusters 2 (4 [3-8]), 3 (3 [0-9]), and 4 (4 [0-7]) than in cluster 1 (0.5 [0-2.0]) and was higher in cluster 2 than in cluster 3., Conclusions: Subjects with ILD were classified into 4 characteristic clusters using dyspnea and S pO 2 at the end of the 6MWT. The 4 clusters are characterized as follows: Cluster 1 had mild desaturation and mild dyspnea; cluster 2 had mild desaturation and severe dyspnea; cluster 3 had both moderate desaturation and dyspnea, and cluster 4 had both severe desaturation and dyspnea. These classification data offer insight for individualized pulmonary rehabilitation for patients with ILD., (Copyright © 2024 by Daedalus Enterprises.)

A woman in her 60s with suspected multicentric Castleman's disease, who was receiving treatment with oral prednisolone, presented to our hospital with mild cough and malaise. Chest CT showed diffuse infiltrative and granular shadows, indicating exacerbation of lung lesions caused by steroid-resistant multicentric Castleman's disease. A video-assisted thoracoscopic lung and mediastinal lymph node biopsy was performed. The biopsy revealed mediastinal lymph node tissue consistent with multicentric Castleman's disease, as well as presence of Cryptococcus neoformans in the alveolar space. C. neoformans infection in immunocompromised individuals may present with diffuse lung lesions and should be noted as a mimicker of acute exacerbation of Castleman's disease., Competing Interests: Competing interests: None declared., (© BMJ Publishing Group Limited 2023. Re-use permitted under CC BY-NC. No commercial re-use. See rights and permissions. Published by BMJ.)

Autoantibodies against aminoacyl-tRNA synthetases (ARSs) are highly specific for myositis and/or interstitial lung disease. We report a rare case of double positive antibodies (anti-EJ antibody, the least common among anti-aminoacyl-tRNA synthetase antibodies, and anti-cyclic citrullinated peptide antibody, reported to be specific for rheumatoid arthritis) in a patient who presented with interstitial lung disease and later developed rheumatoid arthritis. The patient did not have clinically apparent myositis over a period of careful follow-up of several years. The initial pulmonary pathologic findings showed a nonspecific interstitial pneumonia pattern, with the formation of lymphoid follicles, which should be recognized as the first manifestation of rheumatoid arthritis., (2012 The Japanese Respiratory Society. Published by Elsevier B.V. All rights reserved)

Nursing home-acquired pneumonia (NHAP) is a frequent cause of hospital admission and death among residents of long-term care facilities. We studied consecutive patients with NHAP who were admitted to our 358-bed acute care hospital from 2004 to 2007. Patients with NHAP (n = 147) were significantly older (85.8 +/- 8.0 years vs. 80.2 +/- 8.2 years); predominantly female (57.1% vs. 41.5%); had higher severity (the 2005 Japanese Respiratory Society guidelines A-DROP score: 2.5 +/- 1.1 vs. 2.1 +/- 1.2) and a higher mortality (10.4% vs. 5.8%); had a longer median length of hospital stay (17 days vs. 15 days) than elderly patients with community-acquired pneumonia (n = 545). Cerebrovascular disorders (31.3% vs. 14.1%), dementia (59.2% vs. 22.9%) and feeding tube placement (19.0% vs. 6.4%), which were associated with aspiration, were more common and bronchial asthma (0.7% vs. 8.8%) and COPD (4.1% vs. 19.8%) less common among those with NHAP. Although Methicillin-resistant Staphylococcus aureus (MRSA) was more frequently isolated from the sputa of the NHAP group (23.1% vs. 9.4%), Streptococcus pneumoniae was the most important causative agent by microbial investigations, including blood culture and urinary antigen testing in addition to sputum examination.

A 74-year-old woman given a diagnosis of chronic necrotizing pulmonary aspergillosis in February, 2007 was treated by intravenous voriconazole (VRCZ) and her conditions improved. Then it was switched to oral VRCZ and continued treatment. However, a fungus ball remained, and (1-3)-beta-D-glucan values increased, which had previously been within normal limit. Therefore transbronchial intracavitary itraconazole therapy was performed twice a week, for a total of 9 times (715 mg) from June, 2007. The fungus ball disappeared at the time of the fourth injection, and (1-3)-beta-D-glucan values decreased gradually. Intravenous ITCZ was administered for two weeks from July, 2007, after which it was switched to oral ITCZ 400 mg/day and treatment was continued without recurrence. Though intracavitary ITCZ therapy caused temporary fever and elevation of CRP, we were able to perform the treatment safely and confirm the elevation of enough serum ITCZ concentrations. This is the first case of pulmonary aspergilloma successfully and safely treated with transbronchial intracavitary itraconazole.

A 46-year-old woman was referred to our hospital because of abnormal findings of 18F-fluorodeoxyglucose-PET (FDG-PET) scan at a medical check-up. Her chest radiography and CT showed nodular shadows distributed along the broncho-vascular bundle. The 1st FDG-PET showed a high FDG uptake in the pulmonary nodules, and the hilar, mediastinal and supraclavicular lymph nodes. Although sarcoidosis was suspected, diagnosis was not obtained by bronchoscopy. Thoracoscopic lung biopsy was performed in order to exclude malignancy, resulting in a definite diagnosis of sarcoidosis. No treatment was given and subsequently spontaneous regression was obtained. The follow-up FDG-PET showed no abnormal uptake at all. FDG-PET has been widely used in the assessment of malignancy, however recent reports have indicated that sarcoid lesions could have increased FDG activity. FDG-PET may be useful for diagnosis and monitoring in sarcoidosis.

Legionella species have been widely recognized as among the important causative organisms of community-acquired pneumonia in Japan. A delay in the start of adequate treatment has a negative influence on the outcome of the disease. Telithromycin, the first oral ketolide antibacterial, was developed for the treatment of community-acquired pneumonia, including Legionella pneumonia. However, few reports have indicated the efficacy of telithromycin in community-acquired pneumonia caused by Legionella species. We report three cases of Legionella pneumonia, that were improved by early telithromycin therapy. The first patient (67-year-old man) had bronchiectasis as an underlying disease, and the second patient (73-year-old man) had diabetes mellitus and chronic renal failure. The third patient (62-year-old man) developed pneumonia after a spa tour. The diagnosis of Legionella pneumonia was made on the basis of the presence of a single IgG titer of 1/256 in case 1 and positive antigenuria in cases 2 and 3. The patients were classified into a mild group (case 1) and a moderate group (cases 2 and 3) based on the severity of the community-acquired pneumonia according to the 2005 Japanese Respiratory Society Guidelines. The results support the efficacy of telithromycin in mild to moderate Legionella pneumonia.

Aim/methods: A series of 10 cases of chest wall tuberculosis (man/woman=7/3, average age 62 +/- 17 years old) during past seven years were reviewed., Results: Acid-fast bacillus was detected from an abscess in 60% by smear, 30% by culture, and 75% by polymerase chain reaction (PCR). It was characteristic that enhanced CT of abscess revealed a low density mass with peripheral enhancement, 'rim enhancement findings', in all cases. CT also showed ipsilateral pleural thickening in all cases, suggesting lymphogenous pathogenesis of chest wall lesions from tuberculous pleurisy. As for the treatment, antituberculosis chemotherapies were done in all cases. In addition, open drainage was done in 8 cases and curettage of abscess was performed in 5 cases. None of these ten cases had relapsed during the follow-up periods for 12 to 77 months., Conclusions: Chest wall tuberculosis is still important as a disorder of a chest wall mass requiring differential diagnosis. Contrasting CT is thought to be useful for the diagnosis. It should be emphasized that 50% of the cases had good outcome without curettage.

Unlabelled: End-stage renal failure patients on chronic dialysis are high risk groups of tuberculosis due to attenuated cellular immunity. Patients receiving haemodialysis stay prolonged time inside the health-care facilities, thereby increased risk of tuberculosis transmission if a patient has active disease. So management of active pulmonary tuberculosis undergoing haemodialysis is important, however, the number of hospitals which are capable of taking care of such patients is estimated to be few in Japan., Methods: From August 1994 through July 2002, 1059 active pulmonary tuberculosis patients (mean age; 57 +/- 19, male/female = 773/286) were admitted to Nishi-Kobe Medical Center, a 500-bed teaching hospital. Out of them, patients undergoing haemodialysis were retrospectively studied to describe the clinical characteristics of such cases. Then we conducted a questionnaire survey regarding the management of active pulmonary tuberculosis patients undergoing haemodialysis for 86 self-governing bodies in Japan., Results: (1) Clinical characteristics of active pulmonary tuberculosis undergoing haemodialysis. We encountered 14 cases (mean age; 65 +/- 11, male/female = 7/7) of pulmonary tuberculosis undergoing haemodialysis during 8 years. In addition to pulmonary involvement, 3 pleural, one knee joint and one lymph node involvement was detected. Primary renal disease included diabetic nephropathy (n = 3), chronic glomerulonephritis (n = 3), congenital anomaly (n = 1), and unknown (n = 7). Nine cases were referred to our hospital from health-care facilities located out of city or prefecture. In five cases it took more than three months from the onset or detection of abnormal chest X-ray findings to the admission to our hospital. Five cases developed pulmonary tuberculosis within the first year after the initiation of dialysis. None of the patients had a past history of tuberculosis. Cavitary lesion on chest X-ray was observed in only one case. Triple antituberculosis therapy was used in 9 patients, and 4 antituberculosis drugs were used in 5 patients. Antituberculosis therapy was successfully done in all cases except two patients who died of apoplexy and cerebral infarction. (2) The nation-wide questionnaire survey. Of the 86 self-governing bodies we mailed, 66 self-governing bodies replied. Of them, 31% reported that they have experienced difficulties in the management of active pulmonary tuberculosis patients undergoing haemodialysis, and 25% reported the lack of health-care facilities to take care of such cases in their territory. They have referred such patients to hospitals located in the nearby prefectures or they have recommended antituberculosis therapy visiting a local haemodialysis facility., Conclusion: There are sometimes difficulties to manage active pulmonary tuberculosis patients undergoing haemodialysis in Japan. Health-care facilities to take care of such patients should be arranged and the formation of the network is necessarily.

A 55-year-old woman was admitted with a cough and fever in August. A diagnosis of Japanese summer-type hypersensitivity pneumonitis was made on the basis of radiological, serological and pathological findings, in addition to positive returning home provocation. Serum KL-6 was monitored during the clinical course. Although KL-6 fluctuated slowly in comparison with the clinical symptoms and HRCT findings, it was considered useful for confirming the effects of treatment. Serum anti-Trichosporon antibody and the phenotype of HLA were studied in both the patient and her asymptomatic roommate, with whom she had no blood relationship. Though both were sensitized immunologically, HLA-DQ 3, which was reported to be associated with Japanese summer-type hypersensitivity pneumonitis, was detected in the patient but not in her roommate. It was suggested that HLA plays a role in the development of this disease.