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BackgroundHypersensitivity pneumonitis (HP) is classified into nonfibrotic and fibrotic phenotypes. Patients with nonfibrotic HP often experience recurrence and develop fibrosis, whereas those with fibrotic HP have a poor prognosis. Although antigen avoidance has long been the first line of treatment for HP, its impact on prognosis has been poorly reported.MethodsMedical records of 121 patients with HP diagnosed by new diagnostic criteria of American Thoracic Society/Japanese Respiratory Society/Asociación Latinoamericana del Tórax (ATS/JRS/ALAT) guidelines and treated at our institution in Saitama, Japan, were retrospectively analysed. HP was classified into nonfibrotic and fibrotic phenotypes and six HP subtypes: summer-type, bird-related, home-related and occupational HP, humidifier lung, and hot tub lung. Achievement of reduced exposure to inciting agents was divided into complete antigen avoidance (CAA) and incomplete antigen avoidance (IAA) by HP subtype.ResultsOf the 74 patients with nonfibrotic HP, 30 achieved CAA and experienced no recurrence or development of fibrosis. In the remaining 44 patients with IAA, 24 (54.5%) experienced recurrence and/or development of fibrosis. The all-cause 5-year mortality rate in the 47 patients with fibrotic HP was 47.8%. Negative prognostic factors of HP-related mortality in these patients were ConclusionsIn the patients with nonfibrotic HP, CAA resulted in no recurrence or development of fibrosis and longer survival. In the patients with fibrotic HP

BackgroundThe incidence and etiologies of chronic pulmonary infection (CPI) in patients with idiopathic pulmonary fibrosis (IPF) have been poorly investigated. Methods We conducted a retrospective study of 659 patients with IPF to assess the incidence, etiologies, and risk factors of CPI development. CPI was defined if the etiology of infection was diagnosed one or more months after the onset of symptoms or upon the appearance of new shadows on pulmonary radiological images. Results At IPF diagnosis, 36 (5.5%) patients had CPI, and 46 (7.0%) patients without CPI at IPF diagnosis developed CPI over a median follow-up period of 6.1 years. The incidence density of CPI development was 18.90 cases per 1000 person-years. Detected organisms from these 46 patients were Mycobacterium avium complex in 20 patients, othernontuberculous mycobacteria in 4, M. tuberculosis in 7, Aspergillus spp. in 22, and Nocardia sp. in one. In a multivariate Cox regression hazard model, PaO2

Objective The aims of this study were to elucidate the frequency and etiology of community-acquired lobar pneumonia (CALP) and the clinical and radiological differences between CALP and tuberculous lobar pneumonia (TLP). Patients and Methods We retrospectively reviewed medical records of patients with community-acquired pneumonia (CAP) (n = 1032) and tuberculosis (n = 1101) admitted to our hospital. Results Sixty-nine (6.7%) patients with CAP and 23 (2.1%) with pulmonary tuberculosis developed CALP. Legionella species were the most common pathogen (27 patients, 39.1%), followed by Streptococcus pneumoniae (19 patients, 27.5%) and Mycoplasma pneumoniae (18 patients, 26.1%). Symptom duration was longer in the patients with TLP than in those with CALP. On chest radiographs, cavitation in the area of lobar pneumonia and nodular shadows were radiological findings predictive of TLP. High-resolution computed tomography showed cavitation in the area of lobar pneumonia, well-defined centrilobular nodules, and tree-in-bud sign to be the radiological findings predictive of TLP by multivariate logistic regression models. Conclusion Common causes of CALP are Legionella species, S. pneumoniae, and M. pneumoniae. TLP should be considered in patients with lobar pneumonia, particularly in patients with long symptom duration, cavitation, and nodular shadows on chest radiographs, and cavitation, well-defined centrilobular nodules, and tree-in-bud sign on CT.

Kazuyoshi Kurashima,1 Yotaro Takaku,1 Chie Ohta,1 Noboru Takayanagi,1 Tsutomu Yanagisawa,1 Tetsu Kanauchi,2 Osamu Takahashi3 1Department of Respiratory Medicine, 2Department of Radiology, Saitama Cardiovascular and Respiratory Center, Kumagaya, 3Center for Clinical Epidemiology, St Luke’s International Hospital, Tokyo, Japan Background: Emphysema is a distinct feature for classifying COPD, and smoking history (≥10 pack-years) is one of several newly proposed criteria for asthma–COPD overlap (ACO). We studied whether or not a smoking history (≥10 pack-years) and emphysema are useful markers for classifying ACO and differentiating it from asthma with chronic airflow obstruction (CAO). Methods: We retrospectively studied the mortalities and frequencies of exacerbation in 256consecutive patients with ACO (161 with emphysema and 95 without emphysema) who had ≥10pack-years smoking history, 64 asthma patients with CAO but less of a smoking history (

Background: To evaluate the risk factors for pneumonia and the efficacy of the pneumococcal polysaccharide vaccine (PPV) in patients with chronic airflow obstruction. Methods: We retrospectively studied the risk factors for pneumonia in 820 consecutive patients with chronic obstructive pulmonary disease (COPD) (n=509) and patients with asthma-COPD overlap syndrome (ACOS) (n=311). The effects of asthma, age, smoking history, chronic sputum, use of inhaled corticosteroids, percent predicted forced vital capacity (%FVC), percent predicted forced expiratory volume in 1 second (%FEV1), body mass index (BMI), computed tomography (CT)-diagnosed emphysema, and the pneumococcal vaccination on the frequency of pneumonia were assessed. Results: There was no difference in the frequency of pneumonia in patients with COPD and those with ACOS. In a univariate analysis, age (p= 0.031), %FVC (p< 0.001), %FEV1 (p < 0.001), BMI (p = 0.003), the presence of emphysema (p < 0.001) and a history of vaccination with the PPV (p = 0.034) were associated with the frequency of pneumonia. A multivariate analysis identified low BMI, the presence of emphysema and the absence of a pneumococcal vaccination as independent risk factors. The combination index of these factors, the BOVE index, which is calculated from low BMI (

[Objective] Presently, the predominant subtypes of influenza viruses in the world, except for those in local epidemics, include influenza pandemic H1N1 2009 (pH1N1), H3N2, and B viruses. There are few reports on the differences in the clinical features, radiographic findings, treatment, and outcomes of influenza virus-associated pneumonia among these three viral subtypes. The purpose of this study was to investigate whether the clinical features, radiographic findings, treatment, and outcomes differ among the viral subtypes. [Methods] We retrospectively analyzed 96 patients with influenza virus-associated pneumonia whose viral subtypes were clarified. [Results] Patients with pH1N1 virus-associated pneumonia tended to be young. The frequency of primary viral pneumonia differed among the virus-associated pneumonia subtypes (pH1N1, 80%; H3N2, 26.5%; and B, 31%). Patients with pH1N1 virus-associated pneumonia more frequently showed bilateral ground-glass opacities (GGOs), which affected more lobes than in patients with H3N2 and B virus-associated pneumonia. However, patients with H3N2 virus-associated pneumonia showed a higher frequency of consolidation and diffuse bronchial wall thickening than did the patients with pH1N1 virus-associated pneumonia. The severity and mortality did not differ among the three pneumonia subtypes. [Conclusion] In the patients who developed influenza virus-associated pneumonia, those with pH1N1 virus-associated pneumonia frequently developed primary viral pneumonia resulting in bilateral and broad areas of GGOs on imaging, whereas patients with H3N2 virus-associated pneumonia frequently showed consolidation and diffuse bronchial wall thickening on pulmonary imaging.

Background Emphysema is a distinct feature for classifying COPD, and smoking history (≥10 pack-years) is one of several newly proposed criteria for asthma–COPD overlap (ACO). We studied whether or not a smoking history (≥10 pack-years) and emphysema are useful markers for classifying ACO and differentiating it from asthma with chronic airflow obstruction (CAO). Methods We retrospectively studied the mortalities and frequencies of exacerbation in 256 consecutive patients with ACO (161 with emphysema and 95 without emphysema) who had ≥10 pack-years smoking history, 64 asthma patients with CAO but less of a smoking history (

To evaluate the feasibility of automated quantitative analysis with a three-dimensional (3D) computer-aided system (i.e., Gaussian histogram normalized correlation, GHNC) of computed tomography (CT) images from different scanners. Each institution’s review board approved the research protocol. Informed patient consent was not required. The participants in this multicenter prospective study were 80 patients (65 men, 15 women) with idiopathic pulmonary fibrosis. Their mean age was 70.6 years. Computed tomography (CT) images were obtained by four different scanners set at different exposures. We measured the extent of fibrosis using GHNC, and used Pearson’s correlation analysis, Bland–Altman plots, and kappa analysis to directly compare the GHNC results with manual scoring by radiologists. Multiple linear regression analysis was performed to determine the association between the CT data and forced vital capacity (FVC). For each scanner, the extent of fibrosis as determined by GHNC was significantly correlated with the radiologists’ score. In multivariate analysis, the extent of fibrosis as determined by GHNC was significantly correlated with FVC (p

Objective.To review patients with rheumatoid arthritis (RA) receiving biologic therapy following a diagnosis of nontuberculous mycobacterial (NTM) lung disease and to evaluate disease deterioration according to clinical and radiological features and anti-NTM therapy.Methods.We retrospectively analyzed medical records of 11 human immunodeficiency virus-negative patients with RA (median age, 64 years) receiving biologic therapy following diagnosis of NTM lung disease.Results.NTM species included Mycobacterium avium complex in 9 patients (81.8%) and M. gordonae in 2 (18.2%). Underlying respiratory disease was present in 6 patients (54.5%), and most (81.8%) had radiographic features of nodular/bronchiectatic disease. Extent of NTM disease was 1–2 pulmonary lobes in 6 patients (54.5%), 3–4 lobes in 5 patients (45.5%), and 5–6 lobes in none. The results of radiological evaluations were unchanged or improved in 7 patients (63.6%) and worsened in 4 (36.4%). Radiological outcome was worse in patients with poor RA control despite their receiving biologic therapies for RA. Two of 3 patients receiving anti-NTM therapy as initial management for NTM improved, and 1 worsened. Three of 4 patients with worsened radiological outcome had high erythrocyte sedimentation rate (> 50 mm/h).Conclusion.Radiological deterioration was not observed in the majority of patients with RA receiving biologic therapy with NTM lung disease, and radiological outcome of pulmonary NTM was favorable in some patients undergoing anti-NTM therapy. Further studies focusing on disease deterioration according to biologic therapy received during NTM followup are warranted to determine appropriate treatment of RA patients with NTM lung disease.

Objective.The aims of our study were to retrospectively review patients with rheumatoid arthritis (RA) with nontuberculous mycobacterial (NTM) lung disease, to assess the prognostic factors, and to analyze the time to disease deterioration according to the antirheumatic drugs received during the NTM lung disease followup period.Methods.We retrospectively analyzed medical records of 98 HIV-negative RA patients with NTM lung disease treated at our institution, and investigated potential risk factors of mortality with Cox regression analysis. Time to radiologic deterioration was evaluated if antirheumatic drugs were not changed during observational periods and computed tomography was performed once each year.Results.Mean patient age was 67.6 years, and median followup period was 4.4 years. NTM species included Mycobacterium avium complex (83.7%), M. kansasii (6.1%), M. gordonae (6.1%), and others (4.1%). Radiographic features included nodular/bronchiectatic (NB) disease (57.1%), fibrocavitary (FC) disease (14.3%), FC+NB disease (16.3%), and other types (12.2%). Initial management included observation in 74 (75.5%) patients. Negative prognostic factors of mortality were C-reactive protein (CRP) ≥ 1.0 mg/dl and radiographic features of FC, FC+NB, or other disease types. Median time to radiologic deterioration was 3.6 years. Erythrocyte sedimentation rate (ESR) > 50 mm/h was a negative prognostic factor of radiologic deterioration.Conclusion.The most frequent NTM species was M. avium complex. CRP and radiographic features were prognostic factors for all-cause mortality, and ESR was a prognostic factor of radiologic deterioration. Further studies are warranted focusing on time to disease deterioration according to antirheumatic drug received during NTM followup.

Background and objective: In some patients, desquamative interstitial pneumonia may progress to lung fibrosis. The aim of this study was to assess the long-term radiological follow-up results in patients with desquamative interstitial pneumonia. Methods: Among 75 patients suspected of having desquamative interstitial pneumonia, 31 who fulfilled the criteria were included in this study. Clinical characteristics at presentation, responses to treatment and long-term follow-up were evaluated. Results: The 31 patients were predominantly males (94%), and the mean age was 55 years; 93% (28/30) had a history of smoking. The clinical findings included high serum levels of lactate dehydrogenase and immunoglobulin G. Bronchoalveolar lavage (26 patients, 84% of cases) frequently showed an increased percentage of eosinophils (mean 17%). Computed tomography (CT) or high resolution (HR) CT at presentation showed ground glass opacities and/or consolidation in all patients, with one third of patients also showing thin-walled cysts within the ground glass opacities. There was no honeycombing on CT or HRCT scans at presentation. Corticosteroid therapy was effective early in the course of the disease; long-term follow-up (mean 99 months) of 31 patients showed only one death due to progression of the disease, but long-term follow-up of 14 patients (mean 125 months) by HRCT showed the development of new thin-walled cysts and honeycombing in five and lung cancer in four patients, respectively. Conclusions: In a proportion of patients, desquamative interstitial pneumonia may progress to lung fibrosis with honeycombing on HRCT, despite therapy.

Background and objective: In this study the prevalence, lung function and prognosis of IPF combined with emphysema were evaluated. Methods: Consecutive patients with usual interstitial pneumonia (UIP) on high-resolution computed tomography (HRCT), with or without emphysema, were assessed retrospectively. The area of fibrosis in the base of the lungs was assessed by HRCT as minimal (

目的．低濃度職業性石綿曝露に伴う石綿肺の有無，ならびに胸膜プラーク（PP）とusual interstitial pneumonia pattern（UIP/P）との関係を知ること．研究計画．対象は肺葉切除以上の手術がされた1324（男性971，女性353）例．石綿肺の診断は，UIP/Pを示し，3組織切片の鉄染色標本で1組織切片に1.0本以上の石綿小体，石綿肺疑いは1.0本未満の場合とした．結果．石綿肺は7例，石綿肺疑いは4例みられた．石綿小体数は1例を除き1切片中30本以下であった．全例男性で，小葉中心性線維化は4例に，PPは8例に，胸膜肥厚は8例に，胸膜癒着は7例にみられた．PPありの38例（男性36，女性2）のUIP/Pは17例（うち7例は石綿肺と石綿肺疑い）, PPなしの1286例ではUIP/Pは198例（うち4例は石綿肺）で，石綿肺を含むUIP/Pの頻度は1％以下，石綿肺を除いた頻度は5％以下の危険率でPPありに有意に高値であった．結論．特発性肺線維症と考えられる中に石綿肺が紛れている．PPの存在はUIP/Pの危険因子の可能性がある．

The etiology and outcome of diffuse acute infectious bronchiolitis (DAIB) in adults is not well known.To retrospectively review adult patients with DAIB without pneumonia, document the etiologies and outcomes, and assess the relation between DAIB and postinfectious bronchiolitis obliterans.We retrospectively analyzed medical records of 1,664 patients with lower respiratory tract infections admitted to our institution in Saitama, Japan. DAIB was diagnosed when patients developed acute feverish lower respiratory tract infection and chest computed tomography demonstrated mainly multiple centrilobular nodules in four or more lobes. Pneumonia was diagnosed when patients developed acute feverish lower respiratory tract infection and chest computed tomography demonstrated consolidation and/or ground-glass opacities with or without centrilobular nodules.Of the 1,664 patients, 20 (1.2%) and 1,644 (98.8%) patients were diagnosed as having DAIB and pneumonia, respectively. Of the 20 patients with DAIB, the etiology was determined in 16 (80%): 13 (65.0%) had a single pathogen and 3 (15.0%) had two pathogens. Detected organisms included Mycoplasma pneumoniae in eight (40.0%) patients, influenza virus in two (10.0%), influenza virus and Streptococcus pneumoniae in two (10.0%), Haemophilus influenzae in three (15.0%), and respiratory syncytial virus and rhinovirus in one (5.0%) patient. All patients improved and none developed postinfectious bronchiolitis obliterans.The three most common etiologies of DAIB in the studied adults were M. pneumoniae, influenza virus, and H. influenzae. None of the patients with DAIB developed postinfectious bronchiolitis obliterans.

Background Increasing evidence indicates that antineutrophil cytoplasmic antibody (ANCA)-positive conversion occurs in patients initially diagnosed with idiopathic pulmonary fibrosis (IPF) and as a result, some of these patients develop microscopic polyangiitis (MPA). However, the incidence density of these patients is not well known. Objectives To explore the incidence of ANCA-positive conversion and development of MPA during the disease course in patients with IPF and to evaluate whether corticosteroid therapy reduces MPA development in patients with IPF with myeloperoxidase (MPO)-ANCA positivity at diagnosis or who later acquire MPO-ANCA positivity. Methods We retrospectively analysed the medical records of 504 Asian patients with IPF treated at our institution in Saitama, Japan. Results Of the 504 patients with IPF, 20 (4.0%) had MPO-ANCA and 16 (3.2%) had PR-3-ANCA when first evaluated. In 264 of 504 patients with IPF, ANCA was measured repeatedly and seroconversion to MPO-ANCA and PR3-ANCA occurred in 15 (5.7%) and 14 (5.3%) patients, respectively, and 9 of 35 patients who were either MPO-ANCA positive at IPF diagnosis or who subsequently seroconverted developed MPA. None of the nine patients who developed MPA had been previously treated with steroids. The incidence of MPA tended to be lower in patients treated than not treated with corticosteroids although this was not statistically significant. Conclusions Some patients with IPF with MPO-ANCA positivity at IPF diagnosis or with MPO-ANCA-positive conversion during follow-up developed MPA. Clinical trials to determine whether corticosteroid therapy can reduce MPA development and prolong survival in MPO-ANCA-positive patients with IPF should be considered.

Aims We hypothesized that asbestos exposure increases the incidence of macroscopically visible and histologically confirmed usual interstitial pneumonia (histological UIP). Methods and results We retrospectively examined 1718 cases (1202 males; mean age 66.7 years) who underwent lobectomy for resection of pleuropulmonary tumours. Objective markers for asbestos exposure included: the presence of malignant pleural mesothelioma, the presence of pleural plaques (PPs) and asbestos bodies in the histological specimen. Risk factors for histological UIP were examined. Two separate groups were studied: 183 with asbestos exposure, and 239 with histological UIP. The 183 cases with asbestos exposure had higher rates of positive occupational history and histological UIP (31%) than the remaining 1535. Among the asbestos-exposed group, small numbers of asbestos bodies were found in histological specimens of 21 cases of histological UIP. PPs and asbestos bodies were more frequent in the 239 patients with histological UIP than in the remaining 1479 UIP-negative patients. Multivariate analysis showed that asbestos exposure, especially positivity for asbestos bodies, that does not meet the current criteria for asbestosis increases the risk of histological UIP (P

Purpose Airspace enlargement with fibrosis (AEF) has been identified pathologically as a smoking related change. We sought to identify the HRCT findings of AEF and search for distinguishing features from honeycombing. Materials and methods 50 patients (47 males; mean age 69) were evaluated. All had undergone lobectomy for lung cancer and had confirmed AEF and/or usual interstitial pneumonia (UIP) by pathological evaluation. HRCT findings were first evaluated preresection for resected lobes, and then correlated with the subsequent pathological findings in the resection specimens. Three groups were devised: one with AEF alone to determine the HRCT findings of AEF, a second with AEF and UIP and third with UIP alone. HRCT features of AEF and honeycombing were compared. Results There were 11 patients (10 male; mean age 69) with AEF alone, 24 patients (22 male; mean age 69) with AEF and UIP, and 15 patients (15 male; mean age 68) with UIP alone. The HRCT on the AEF alone showed subpleural (but not abutting the pleura) multiple thin-walled cysts (MTWCs) in 7 and reticular opacities in 3. The HRCT in AEF and UIP showed MTWCs in 10, reticular opacities in 17; and honeycombing in 5. Among these 35 patients with the pathological finding of AEF (with or without UIP), 17 showed MTWCs. The maximum cyst wall thickness of MTWCs (mean 0.81 mm) was significantly thinner than that of honeycombing (mean 1.56 mm). MTWCs did not locate in lung base and was distant from the pleura. HRCT findings correlated with gross findings on both cysts and honeycombing. No MTWCs were seen in the 15 patients with UIP, 8 of 15 had honeycombing on CT. Conclusions We confirmed that HRCT features of AEF were MTWCs and/or reticular opacities. MTWCs might be distinguished from those of honeycomb change. While we prefer the term MTWCs, these sorts of changes have probably been confused with/interpreted as honeycombing and/or empysema in the past.

Background: COPD is defined by airflow limitation that is not fully reversible and is associated with relevant risk factors. The diagnosis requires that other causes of chronic airflow limitation (CAL) be excluded. We assessed the diagnostic utility of high resolution thoracic CT (HRCT) and bronchodilator reversibility to assist in making a diagnosis of COPD. Methodology: We investigated 516 consecutive patients whose FEV1/FVC was less than 70% after inhalation of bronchodilator. HRCT was performed on all subjects and a final diagnosis was made only after 3 months of treatment and repeated spirometry. Results: Of 516 cases, 54.3% had COPD, 19.8% had asthma plus emphysema, and 13.2% had chronic asthma. The remaining 12.7% of patients with CAL had diffuse panbronchiolitis, bronchiectasis, bronchiolitis obliterans, or other miscellaneous diseases. In these minor diseases HRCT was essential in making a definitive diagnosis. The sensitivities of emphysema on HRCT and of absence of bronchodilator response for the diagnosis of COPD were 81% and 90%, respectively, and the specificities of the tests were 57% and 37%, respectively. In addition, HRCT revealed considerable heterogeneity of COPD. Emphysema was not recognized on HRCT in 18.6% of COPD patients. HRCT also revealed that 17.5% of COPD patients had other pulmonary complications including lung fibrosis compatible with usual interstitial pneumonia in the lung bases. Conclusions: HRCT and the bronchial reversibility test had reasonable sensitivities but low specificities for diagnosing COPD. HRCT has some additional advantages in detecting heterogeneity and concomitant lung diseases in COPD.

背景. 肺腺癌, 特に粘液産生性細気管支肺胞癌は, しばしば経気道転移を起こし, 胸部X線写真や胸部CTで肺胞性陰影を呈することがある. 我々は, 粘液非産生性乳頭型腺癌でありながら, 著明な経気道転移のために広範な肺胞性陰影を呈した症例を報告する. & 症例. 73歳男性. 平成10年9月に肺癌に対して右中葉切除およびS3, S8部分切除を施行した. 組織型は粘液非産生性中分化型乳頭型腺癌で, 中心部には線維化を伴い, 辺縁部では立方状の癌細胞が肺胞壁を被覆したり肺胞壁との連続を持たずに肺胞腔内に浮遊し充満する像を認めた. 葉間胸膜を越えるS3への進展があり, pT3 N0 M0, stage IIIAであった. 1年後右S6に転移が出現し部分切除を受けた. さらに1年後右S2に腫瘤と下葉に広範な肺胞性陰影が出現し, 右肺切除が施行された. S2の腫瘤は中心部に線維化を伴う中分化型乳頭型腺癌で, 下葉には広範な癌細胞の肺胞腔内への浮遊を認めた. 結論-肺胞性陰影は, 経気道性に広範な転移をきたした結果と考えられた. 本症例は間質の線維化を伴う粘液非産生性乳頭型腺癌で, 経気道転移により広範な肺胞性陰影を呈した特殊な例であった.

手術の行われた原発性肺癌で肺梗塞を合併した3例 (扁平上皮癌1例, 非定型カルチノイド1例および腺癌1例) について, CT所見と切除肺の肉眼所見および病理組織所見を対比検討した.梗塞巣は合計13個で, いずれも浸潤により狭窄した肺動脈の支配領域に存在していた.胸膜から離れた病変が7個, 胸膜面に接する病変が6個認められた.2例では中枢肺動脈と肺静脈の両方の狭窄が認められたが, 1例では肺動脈の狭窄のみで肺静脈は保たれていた.肺癌に伴う肺梗塞のCT所見の特徴は, 浸潤により狭窄した肺動脈の支配領域に存在すること, 胸膜から離れた結節と胸膜面に接する結節がほぼ同じ頻度で観察され, 気管支肺動脈束に沿う分布を示す場合もあること, 周囲にスリガラス状陰影を伴う新鮮な病変や, 小葉間隔壁で境界されるため直線的辺縁を有する病変, 収縮性変化を伴う古い病変など発症時期の異なる多彩な病変が同時に観察されること, である.

Objective CT-diagnosed emphysema is associated with poor prognosis in chronic obstructive pulmonary disease (COPD). Its clinical impacts on prognoses of asthma with chronic airflow obstruction (CAO) are not well known. We sought to compare mortalities and prognostic factors in COPD and asthma with CAO by the presence or absence of CT-diagnosed emphysema. Design Retrospective cohort study. Setting Referral centre hospital for respiratory disease. Participants 1272 patients aged over 40 years with CAO (January 2000 to December 2011). CAO was defined as a forced expiratory volume in 1 s/forced vital capacity

Kazuyoshi Kurashima,1 Toshiko Hoshi,2 Yotaro Takaku,1 Tetsu Kanauchi,2 Keitaro Nakamoto,1 Miyuki Ueda,2 Noboru Takayanagi,1 Thomas V Colby,4 Yutaka Sugita,1 Yoshinori Kawabata3 1Department of Respiratory Medicine, 2Department of Radiology, 3Department of Pathology, Saitama Cardiovascular and Respiratory Center, Kumagaya City, Saitama, Japan; 4Department of Laboratory Medicine and Pathology, Mayo Clinic, Scottsdale, AZ, USA Background: The purpose of this study was to examine changes in the airway lumen and parenchyma in relation to lung function in patients with chronic obstructive pulmonary disease (COPD) compared with controls. Methods: We studied 70 patients with COPD and 15 normal subjects. Using reconstructed computed tomography (CT) images, we traced the bronchial trees and reconstructed 3 cm circle images around the airways exactly perpendicular to the airway axis at the peripheral, middle, and central zones of the bronchi. We measured the number of airways and vessels, the airway inner diameter, and the area of emphysema in the circles, and analyzed the relationship of these image parameters to lung function. Results: Reduced airway numbers and increased upper lobe emphysema were observed even in early spirometric stages in patients with COPD compared with controls. Other findings included decreased airway inner diameter in advanced spirometric stages. The numbers of peripheral zone bronchi, the extent of the middle zone emphysematous area, and the mean airway inner diameter of the airways were the best predictors of spirometric parameters. A portion of the airways in patients with COPD showed a loss of airway patency at middle or central zone bronchi predominantly in the late spirometric stages. Lumen-obliterated bronchial trees could be traced into emphysematous areas showing air trapping. Conclusion: Compared with controls, our CT observations in patients with COPD showed that airway lumen and lung parenchyma changes along airways differed by spirometric stage, and these changes were associated with decreased lung function. A portion of CT-identified emphysema in patients with COPD appeared to be due to lumen-obliterated airways in the bronchial tree. Keywords: airway dimension, computed tomography, emphysema, pulmonary functions

OBJECTIVE The prognostic factors of chronic necrotizing pulmonary aspergillosis remain unclear. We assessed the prognostic factors of all-cause mortality in patients with chronic necrotizing pulmonary aspergillosis, focusing especially on underlying pulmonary disease, first-line treatment and host predisposition. METHODS We retrospectively analyzed the medical records of 194 patients negative for HIV who had chronic necrotizing pulmonary aspergillosis treated at our institution in Saitama, Japan. RESULTS The patients (median age, 68.5 years) were followed over a median follow-up time of 2.6 years. The underlying pulmonary diseases consisted of previous pulmonary tuberculosis in 59 (30.4%) patients, emphysema in 39 (20.1%) patients, interstitial lung disease in 32 (16.5%) patients, nontuberculous mycobacteriosis in 29 (14.9%) patients and other diseases in 35 (18%) patients. The first-line treatments included observation in 65 (33.5%) patients, itraconazole in 56 (28.9%) patients, micafungin in 46 (23.7%) patients, voriconazole in 22 (11.3%) patients and amphotericin B (including liposomal amphotericin B) in five (2.6%) patients. The overall cumulative mortality rate was 50.2% at five years and 67.4% at 10 years. Multivariate Cox proportional hazard modeling found an older age, the presence of systemic comorbidities, baseline corticosteroid use, a body mass index of

The prognostic factors of Mycobacterium avium complex lung disease (MAC-LD) are not clearly defined.To assess the prognostic factors of all-cause and MAC-specific mortality in patients with MAC-LD, especially in accordance with radiographic features, first-line treatment, and host predisposition.Medical records of 634 HIV-negative patients with MAC-LD treated at our institution in Saitama, Japan were retrospectively analyzed.Patients' mean age was 68.9 years, and median follow-up period was 4.7 years. Radiographic features included nodular/bronchiectatic (NB) disease: 482 patients (76.0%); fibrocavitary (FC) disease: 105 patients (16.6%); FC+NB disease: 30 patients (4.7%); and other types: 17 patients (3.0%). First-line treatments were observation or one drug: 479 patients (75.6%); 2 to 5 drugs: 131 patients (20.7%); and unknown: 24 patients (3.8%). A multivariate Cox proportional hazard model showed male sex, older age, presence of systemic and/or respiratory comorbidity, non-NB radiographic features, body mass index (BMI) less than 18.5 kg/m(2), anemia, hypoalbuminemia, and erythrocyte sedimentation rate greater than or equal to 50 mm/h to be negative prognostic factors for all-cause mortality, and FC or FC+NB radiographic features, BMI less than 18.5 kg/m(2), anemia, and C-reactive protein greater than or equal to 1.0 mg/dl to be negative prognostic factors for MAC-specific mortality.The first-line treatment regimen was not associated with all-cause mortality. FC or FC+NB disease, BMI less than 18.5 kg/m(2), and anemia were negative prognostic factors for both all-cause and MAC-specific mortality.

We analyzed the routes of draining veins in 7 cases of intralobar pulmonary sequestration (ILS) and 6 cases of bronchial atresia (BA) by multidetector CT and on 3D reconstructed images. In 2 cases of ILS with systemic venous drainage and 4 of 5 cases with pulmonary venous drainage, the primary veins penetrated the abnormal lungs. In another case, the main vein bypassed the border of the lung, but a small number of branches joined from the normal lung. In all cases of BA, draining veins distributed outside the abnormal lung. The finding that ILS has its own draining veins supports the theory of its congenital origin from an accessory lung bud.

We encountered 2 patients with novel influenza A (H1N1) pneumonia initially treated with steroid therapy after an incorrect diagnosis of cryptogenic organizing pneumonia and acute interstitial pneumonia, made because of atypical radiological findings and negative rapid antigen test results. After the patients were discharged, we performed reverse-transcriptase polymerase chain reaction tests for the presence of novel influenza A (H1N1); the results were positive, and we established the correct diagnosis of infection by novel influenza A (H1N1) virus pneumonia. Diagnostic clues included radiological findings similar to those of previously reported cases of novel influenza A (H1N1) virus pneumonia and an increase in similar cases due to the novel influenza A (H1N1) pandemic, suggesting that these 2 patients were also suffering from it. Similar cases of inappropriate treatment resulting from an initially incorrect diagnosis of cryptogenic organizing pneumonia or acute interstitial pneumonia may occur, and greater attention should be paid to accurate diagnosis.

A 55-year-old man was admitted to our hospital with chronic cough. Although his chest X-ray was normal, chest computed tomography revealed a nodular lesion that was causing beaded stenosis of the lumen of the upper lobe bronchus. Nodules approximately 10 mm in size were seen in the mediastinum. We could not deny the possibility of vascular disease, and enhanced chest computed tomography was performed, which showed these abnormalities to be caused by a dilated and convoluted bronchial artery. Because no pulmonary diseases that would lead to secondary vascular dilatation were evident, a diagnosis of primary racemose hemangioma of the bronchial artery was made. We performed bronchial artery embolization to prevent potential fatal bleeding from vascular rupture. The patient has been followed regularly as an outpatient, and recanalization has not been detected. Primary racemose hemangioma of the bronchial artery is a rare entity; it is also rare for this entity to be detected by findings of a nodular protrusion in the bronchial wall or in a patient presenting with a cough. Here, we report this case and review previous reports.

Background and objective The effects of tiotropium, a long-acting anticholinergic drug, were compared with those of the combination of salmeterol, a long-acting beta(2)-agonist, and fluticasone, an inhaled corticosteroid, in patients with COPD. Methods A 4-month, randomized, open cross-over study of tiotropium, 18 microg once daily, versus salmeterol, 50 microg, plus fluticasone, 200 microg, twice daily, was conducted in patients with COPD. Efficacy was assessed by spirometry and responses to the St George's Respiratory Questionnaire (SGRQ). After 4 months, patients were asked to select their subsequent therapy and indicate the reasons for their selection. Results A total of 78 patients completed the study. There were no significant differences in the improvements in FEV(1) or SGRQ scores between the therapies. Similar numbers of patients selected tiotropium (42.3%) and salmeterol plus fluticasone (57.7%). However, those who preferred one of the therapies demonstrated greater improvements in SGRQ scores with that therapy. One subgroup of patients (30.8%) showed greater improvements in dyspnoea and FEV(1) in response to tiotropium, and the other subgroup of patients (35.9%) showed greater improvements in dyspnoea and FEV(1) in response to salmeterol plus fluticasone. Some patients (14.1%) selected salmeterol plus fluticasone because of positive effects on sputum expectoration. Conclusions The study was unblinded and the results need to be interpreted with caution. However, tiotropium and salmeterol plus fluticasone had similar overall effects on pulmonary function and SGRQ scores in patients with COPD. Responses to the two therapies were heterogeneous, and the patients who showed greater improvements in FEV(1) or SGRQ scores with one of the therapies preferred it for their subsequent treatment.

Background and objective: The aim of this study was to determine whether early versus late initiation of long-term inhaled corticosteroid (ICS) therapy decreases airway wall thickness in patients with asthma. Methods: One hundred and eighty-one patients with asthma not previously treated with ICS were given inhaled budesonide for 1 year. These patients were divided into five groups according to the duration of their asthma symptoms, which ranged from less than 1 year to more than 10 years. High-resolution CT images and post-bronchodilator FEV1 were examined before and 1 year after treatment. Results: Before treatment, airway wall thickness was increased relative to the duration of asthma. Disease severity improved with ICS treatment even in patients who had suffered asthma symptoms for more than 10 years. Post ICS treatment, airway wall thickness decreased in patients with a duration of symptoms less than 3 years, and a minor response was seen in patients with a duration of symptoms from 3 to 5 years. However, there was no change in airway wall thickness in patients who had suffered asthma for more than 5 years. Post-bronchodilator FEV1 improved only in patients who had suffered asthma for less than 3 years. Conclusions: ICS therapy may improve asthma control in all asthma patients despite the disease duration, but early ICS treatment may be critical to reverse airway wall thickening associated with asthma.

Objectives Some patients with nodular/bronchiectatic Mycobacterium avium complex lung disease (NB MAC-LD) deteriorate and die. The main aim of the study is to evaluate the prognostic factors and radiographic outcomes in patients with NB MAC-LD. Setting Retrospective single-centre review. Participants 782 HIV-negative patients with NB MAC-LD treated at our institution in Japan. Primary and secondary outcome measures All-cause and MAC-LD progression mortality rates and the prognostic factors, and radiographic deterioration rates and the prognostic factors. Results Mean age was 68.1 years, and median follow-up period was 4.3 years. Death from any cause and progression of MAC lung disease (MAC-LD) occurred in 130 (16.6%), and 19 (2.4%) patients, respectively. All-cause and MAC-LD progression 10-year mortality rates were 27.4% and 4.8%, respectively. In 536 patients with MAC-LD who were followed-up for more than 1 year, radiographic deterioration occurred in 221 (41.2%) patients and median time-to-radiographic deterioration was 9 years. A multivariate Cox proportional hazard model showed male sex, older age, body mass index 40 mm/h to be negative prognostic factors for all-cause mortality, and the presence of idiopathic pulmonary fibrosis, haemoglobin 1.0 mg/dL and the presence of cavity to be negative prognostic factors for radiographic deterioration. Conclusions Only 2.4% of patients with NB MAC-LD died from MAC-LD progression. As clinical trials testing the effectiveness of drug therapy in patients with NB MAC-LD are being designed and implemented, the primary end point could be time-to-radiographic deterioration, and trial patients need to be stratified according to these prognostic factors before randomisation.

Kazuyoshi Kurashima,1 Yotaro Takaku,1 Toshiko Hoshi,2 Tetsu Kanauchi,2 Keitaro Nakamoto,1 Noboru Takayanagi,1 Tsutomu Yanagisawa,1 Yutaka Sugita,1 Yoshinori Kawabata3 1Respiratory Medicine, 2Radiology, 3Pathology, Saitama Cardiovascular and Respiratory Center, Saitama, Japan Objective: The aim of this study was to evaluate the relationship between computed tomography assessed lobe-based lung parameters and the clinical outcomes of patients with chronic obstructive pulmonary disease (COPD), including the frequency of exacerbation and annual change in forced expiratory volume in 1 second (FEV1). Patients and methods: We studied 65 patients with COPD. We reconstructed computed tomography images to trace the bronchial tree from right B1 to B10 and created 3 cm circle images around the airways exactly perpendicular to the airway axis in the central, middle, and peripheral zones of the bronchi. The number of airways and vessels, airway inner diameter and area of emphysema in the circles were calculated for each segment. Then, we analyzed the relationships between the lobe-based image parameters and the frequency of exacerbation and annual decline in the FEV1. In addition, we assessed the effects of proximal airway lumen-obliterated emphysema (ALOE) on these clinical features. Results: The airway diameter was not associated with the frequency of exacerbation or annual decline in FEV1. Among the structural parameters, lower lobe emphysema was most associated with the frequency of exacerbation. The reductions in the number of airways and vessels in total lobe were associated with the annual decline in FEV1. The subgroup of patients with ALOE demonstrated lower FEV1 and more frequent exacerbation than those without ALOE. Conclusion: Lower lobe emphysema predicts frequent COPD exacerbation, whereas the annual decline in FEV1 is associated with the number of airways and vessels in total lobe. Keywords: chronic obstructive pulmonary disease, computed tomography, acute exacerbation, pulmonary function tests, low attenuation area&nbsp

The purpose of this study was to clarify the characteristic CT findings of pulmonary hamartoma.The thin-section CT and multiplanar reformation images of 19 pulmonary hamartomas diagnosed by surgical resection were analyzed and correlated with the pathological findings.Most hamartomas presented lobulated nodules apart from pleura. There was no case in which fat density was recognized. Only one case was recognized as having calcification. Air density in the connection of the side or the inside was pointed out in 5 cases (26%). Air density reflected epithelial-lined cleft. The connection with the bronchus was recognized in 4 cases (21%), and the connection with the pulmonary artery branch was recognized in 10 cases (53%). However, the connection of the pulmonary artery and bronchus could not be pathologically confirmed in most cases. The connection with the pulmonary vein was not recognized in any of the cases.Air density in the connection of the side or the inside is characteristic of pulmonary hamartoma. Pulmonary artery branches connect beyond half of hamartomas. This finding suggests close relations in the bronchus along the artery. It is important that there is no connection of the pulmonary vein, to differentiate it from lung cancer.

Purpose The purpose of this article is to describe the radiologic findings to diagnose congenital bronchial atresia. Methods Chest radiographs, CT scans, and MRI of nine patients with congenital bronchial atresia were reviewed. Results Six patients (67%) had hilar mass-like shadows and hyperlucency of the peripheral lung field on chest radiographs. On chest CT scans, all patients demonstrated mucocele, occlusion of bronchus central to mucocele, and emphysematous change of the peripheral lung field. On chest MRI, performed in seven patients, all mucoceles demonstrated very high signal intensity on T2-weighted image, indicating that mucoceles were filled with fluid. Conclusion Diagnosis of congenital bronchial atresia can be confirmed based on the findings of chest CT: mucocele, occlusion of bronchus central to mucocele, and emphysematous change of the peripheral lung field.