20190731Miscellaneous kazuma kishi respirasi.pptx

respirasi paru

1. Miscellaneous Kazuma Kishi , M.D. Department of Respiratory Medicine, Toho University School of Medicine July 31, 2019 The Training of High Resolution CT reading Hotel Borobudur, Jakarta

2. Case 1 69-year-old woman Non-smoker Fever and headache A diagnosis of brain abscess was made She was referred to our hospital

3. Brain Abscess

4. What is the diagnosis?

5. Multiple a rteriovenous malformations → Osler-Weber- Rendu syndrome （ Hereditary Hemorrhagic Telangiectasia ）

6. Pulmonary Arteriovenous Malformations 35%-67% associated with Osler-Weber- Rendu syndrome Multiple 35%, Bilateral 10% Complications: paradoxical embolization Simple AVM: one feeding artery/one draining vein Complex AVM: multiple feeding vessels Most common in lower lobe, subpleural Treatment is by embolization

7. 67-year-woman with cerebellar infarction Akiyama et al. Intern Med2013;52:1091-1094 An axial MRI scan obtained using diffusion-weighted imaging reveals a high-intensity signal in the right cerebellar infarction.

8. Family History

9. Telangiectasias Telangiectasias are present on the patient’s right first finger and tongue.

10. VATS was performed. Some turbulent thrombi can be identified in the pulmonary arteriovenous malformation located in the right S2 segment (arrow).

11. The pathological findings of the pulmonary arteriovenous malformations show intimal thickening and organizing mural thrombi (arrows) that were observed during VATS.

12. Case 2 49-year-old man He started working with an electric power company in Arizona four months ago He presented with fever and cough Chest radiograph showed pneumonia Minocycline and then prednisolone was prescribed, but his symptoms did not improve. He returned to Japan, and visited our hospital.

13. What is the diagnosis? Pulmonary Coccidioidomycosis

14. Geographic distribution of coccidioidomycosis Emerg Infect Dis 2:192, 1996

15. Satellite photo

16. The trend of imported mycosis in Japan coccidioidomycosis histoplasmosis

17. Itraconazole 400 mg/day T 3 months T 6 months T 0

18. Pulmonary Coccidioidomycosis Primary pulmonary coccidioidomycosis Residual or chronic pulmonary coccidioidomycosis (5%) Nodules ( coccidioidomas ) Cavities Chronic progressive pneumonia Disseminated coccidioidomycosis (<0.5%)

19. Patients’ Characteristics Case Age/ Sex Occupation Infection place Infection time Initial symptoms Mode of detection 1 30/M Pilot trainee (A airline) Bakersfield, California Aug, 2004 None Medical check-up 2 33/M Pilot trainee (A airline) Bakersfield, California May, 2005 Fever, Erythema nodosum Medical check-up 3 27/M Pilot trainee (B airline) Bakersfield, California May, 2004 Fever, chest pain Medical check-up 4 65/M None Arizona July, 2005 None Medical check-up Kishi K, et al. Respirology 2008;13:252-6

20. Bakersfield, California

21. HRCT Case 1 Case 3 Case 2 Case 4A Case 4B

22. Cavitary Coccidioidomycosis (Case 4)

23. M 1 2 3 4 B C 239 bp PCR analysis PCR amplification of Coccidioides immitis (or C. posadasii )-specific genomic DNA from the patients ’ lung tissues. Lanes 1-4: Cases 1-4, respectively; M: molecular size marker ( φ X174/ HaeIII digest); B: a negative PCR control with no template DNA; C: a positive control. A 239-bp PCR product (arrow) is seen in the samples of the four patients on a 3% NuSieve 3:1 agarose gel.

24. Case 3 79-year-old man Former smoker, 15 pack-years An abnormal chest shadow was detected at medical-check up Body weight loss – 3kg/3 months

25. a What is the diagnosis?

26. Transthoracic Needle Biopsy Bronchoscopy M. tuberculosis (6colony)

27. T 4 months T 0

28. 76-year-old woman with non-tuberculosis mycobacterial infection

29. Case 4 33-year-old woman Never smoked Hemoptysis

30. Hodgkin’s Lymphoma

31. Hodgkin’s Lymphoma Peak incidence in the third and eighth decades Lymph node involvement in nearly all with thoracic involvement Superior mediastinal node enlargement in 98% Lung disease 10% had lung involvement Nearly always associated with enlarged nodes Direct infiltration, lung nodules, consolidation

32. 39-year-old man presenting dyspnea

33. Non-Hodgkin’s Lymphoma

34. Case 5 48 year-old-man Non-smoker Asymptomatic Chest radiographic abnormality

35. Primary Pulmonary Cryptococcosis

36. Patients characteristics of 22 patients with pulmonary cryptococcosis Characteristics No. of patients (%) Gender, Men/Women 17/5 Mean age, yr 54 Host status Immunocompetent 13 (59) Immunocompromised 9 (41) Underlying conditions Diabetes mellitus 7 (32) Autoimmune pancreatitis /lymphoma 1/1 Corticosteroid therapy 3 Symptoms None 19 (86) Cough /General fatigue 2/1 Mode of detection Mass screening 15 (68) Routine follow-up of other diseases 5 (23) Symptoms 2 (9) Kishi K, et al Respir Med 2006;100:807-812

37. HRCT Findings Characteristics No. of patients (%) Nodular pattern 20 (91) Solitary nodule 12 (55) Multiple nodules 8 (36) Consolidation 2 (9) Parenchymal lesions were located in the peripheral area of the lung in 20 of 22 patients (91%).

38. HRCT Findings of Pulmonary Nodules in 20 Patients Characteristics No. of patients (%) Nodular Margin Well defined 17 (85) Poorly defined 5 (15) Irregular 12 (70) Smooth 6 (30) Spiculation 6 ( 30 ) Lobulation 7 ( 35 ) Convergence of pulmonary vessels 10 (50) Pleural indentation 10 (50) Internal characteristics Cavity 6 ( 30 ) Air- bronchogram 7 (35)

39. A B C Cryptococcosis mimicking lung cancer

40. A B C Cryptococcosis mimicking TB

41. Case 6 19-year-old woman Never smoked Sinusitis since 15 years of age Cough and sputum

42. Diffuse P anbronchiolitis (DPB)

43. 64-year-old man with advanced DPB

44. Take Home Messages Overseas travel history is important to diagnose coccidioidomycosis or histoplasmosis Pulmonary cryptococcosis occurs in healthy subjects mainly showing nodules on HRCT Peripheral nodules with feeding/draining vessels indicate arteriovenous malformations PET-positive lesions are not specific to cancer Diffuse centrilobular nodules with bronchiectasis and presence of sinusitis suggest diffuse panbronchiolitis