杏林大学呼吸器内科　『あんずの呼吸 part2』

Evidence of Pulmonary Disseminated Cryptococcosis: Diffuse Multiple Micronodules on Thoracic Computed Tomography

Am J Med 2014

Takeshi Saraya, MD, PhD, Hajime Takizawa, MD, PhD
Department of Respiratory Medicine, Kyorin University School of Medicine, Tokyo, Japan

Rothia aeria: a great mimicker of the Nocardia species.

Saraya T, Yonetani S, Ogawa Y, Tanaka Y.

BMJ Case Rep. 2014 Dec 3;2014. pii: bcr2014206349. doi: 10.1136/bcr-2014-206349.

PMID: 25471108

Spontaneous Resolution of PCP on HRCT in a Patient with Renal Cell Carcinoma.

Tanaka Y, Saraya T, Kurai D, Ishii H, Takizawa H, Goto H.

Am J Case Rep. 2014 Nov 14;15:496-500. doi: 10.12659/AJCR.890947.

Abstract
Background Spontaneous resolution of Pneumocystis jirovecii pneumonia has rarely been reported.

Case Report A 59-year-old man presented to our hospital because of pyrexia (38°C) and shaking chills for 2 days.
He had a history of right nephrectomy due to renal cell carcinoma and left upper lobectomy for lung metastasis in the last 1.5 years.
Two months previously, he was treated with oral prednisolone (20 mg/day) plus the intravenous mTOR inhibitor, temsirolimus (25 mg/week),
for brain metastasis. On radiological examination, thoracic computed tomography showed diffuse ground glass opacities
spreading in bilateral middle to lower lung fields. Although transbronchial biopsy specimens and
bronchoalveolar lavage fluid demonstrated the presence of accumulation of black-colored
Pneumocystis jirovecii cysts in the lung, his chief complaints and radiological abnormalities disappeared completely
with no treatment. This case demonstrates a unique clinical presentation of Pneumocystis jirovecii pneumonia,
in that spontaneous resolution was noted on clinical and sequential radiological evaluations.

Conclusions Increasing numbers of cytotoxic drugs and biological therapies have emerged, and changes in the immune status
due to underlying diseases or administration of immunosuppressive drugs might affect the inflammatory process of
Pneumocystis jirovecii pneumonia, as in the present case.

http://www.cyoshinnosusume.com/indeex1.html

素晴らしい会です！

Renal Salt Wasting Syndrome due to Carboplatin in a Patient with Lung Cancer

Pulm Res Respir Med Open J . 2014; 1(1): 9-12.

Satoshi Toriumi, Takeshi Saraya, Naoki Tsujimoto, Takeshi Nosaka, Hidemi Kanno,
Hikaru Kukimoto, Sho Sakuma, Yohei Nagamine, Kosuke Ohkuma, Mitsuru Sada, Hiroki
Nunokawa, Yasutaka Tanaka, Takuma Yokoyama, Saori Takata, Takashi Koide, Daisuke
Kurai, Hiroo Wada, Haruyuki Ishii, Hajime Goto and Hajime Takizawa

現時点で210名を越える応募があったようです。
まだ参加可能だと思います。
よろしくお願いします！

第12回のテーマ：典型症例の非典型的なプレゼンテーション
～解決への糸口を掴むためには？ 1000本ノック：症例から学ぶ～

記

日程
日時：平成26年8月24日（日曜日）12時15分～17時（受付開始：12時～）
場所：東京大学医学部「鉄門講堂」（教育研究棟14階）
〒113-8655　東京都文京区本郷7-3-1
TEL：03-3815-5411（代表）、地図は下記URLを参照
東京大学本郷キャンパス
（http://www.u-tokyo.ac.jp/campusmap/cam01_02_09_j.html）
内容
12時15分～12時20分
開会挨拶、イントロダクション

12時20分～12時50分
Case based approach: Common diseaseのuncommon presentation
“1000本ノックpart1”
杏林大学　呼吸器内科　皿谷　　健

12時45分～13時
日常臨床にグラム染色を生かすために“喀痰の貪食像って意味あるの？”
杏林大学　呼吸器内科　下田　真史

13時～14時
ケースカンファレンス1＆ミニレクチャー（免疫不全感染症に立ち向かうために）
虎の門病院　臨床感染症部　臨床感染症科 荒岡　秀樹

14時～15時
ケースカンファレンス2＆ミニレクチャー（肺炎の非典型例に立ち向かうために）
杏林大学　呼吸器内科　本多紘二郎

15時～15時15分
休憩

15時15分～15時45分
症例の1000本ノックpart2
東京女子医科大学病院　感染症科　藤田　崇宏

15時45分～16時15分
症例の1000本ノックpart3
亀田総合病院　感染症科　細川　直登

16時15分～16時45分
症例の1000本ノックpart4“検体検査が診断に寄与した症例”
杏林大学医学部附属病院　臨床検査部　米谷　正太

16時45分～17時
質疑・応答、総括、閉会
参加申し込み方法
申込み方法
参加を希望される方は、(1)氏名（フリガナ）、(2)職種、(3)施設名、(4)所属、(5)連絡先E-mailを記載の上、
下記の日本臨床微生物学会事務局宛E-mailまたはFAXにてお申し込みください。
E-mail：jscm@qk9.so-net.ne.jp　FAX：03-5437-1488
申込み締切り
平成26年8月12日（火曜日）必着
定員
200名：定員を超えた場合は、職種により出席者構成を考慮して選考させていただきます。

参加資格は日本臨床微生物学会の会員・非会員の区別は問いません。
参加費（会員、非会員）2,000円
※参加の確定をE-mailまたはFAXでご案内します。ご案内が届きましたら、指定の口座へ事前にお振り込みをお願いします。
感染症学セミナーWG担当委員：
細川　直登、大塚　喜人（亀田総合病院）、大楠　清文（東京医科大学）、藤田　崇宏（東京女子医科大学）、
皿谷　　健（杏林大学）、佐藤　智明（東京大学）、西　　圭史（杏林大学）

我々の悲願であったマイコプラズマ肺炎総説が出ました！
沢山の先生方、仲間の協力があってこそ成しえた仕事です。
関わって下さった全ての皆様に感謝申し上げます！

Novel aspects on the pathogenesis of Mycoplasma pneumoniae pneumonia and therapeutic implications


Takeshi Saraya1, Daisuke Kurai1, Kazuhide Nakagaki2, Yoshiko Sasaki3, Shoichi Niwa3, Hiroyuki Tsukagoshi3, Hiroki Nunokawa1,
Kosuke Ohkuma1, Naoki Tsujimoto1, Susumu Hirao1, Hiroo Wada1, Haruyuki Ishii1, Koh Nakata4, Hirokazu Kimura5, Kunihisa Kozawa3,
Hajime Takizawa1 and Hajime Goto1*

Front. Microbiol., 11 August 2014 | doi: 10.3389/fmicb.2014.00410
Review Article

1Department of Respiratory Medicine, Kyorin University School of Medicine, Mitaka, Japan
2Department of Virology and Immunology, College of Veterinary Medicine, Nippon Veterinary and Animal Science University, Mitaka, Japan
3Gunma Prefectural Institute of Public Health and Environmental Sciences, Maebashi, Japan
4Bioscience Medical Research Center, Niigata University Medical and Dental Hospital, Niigata, Japan
5Infectious Disease Surveillance Center, National Institute of Infectious Diseases, Tokyo, Japan

Mycoplasma pneumoniae (Mp) is a leading cause of community acquired pneumonia. Knowledge regarding Mp pneumonia obtained from animal models or
human subjects has been discussed in many different reports. Accumulated expertise concerning this critical issue has been hard to apply clinically,
and potential problems may remain undiscovered. Therefore, our multidisciplinary team extensively reviewed the literature regarding Mp pneumonia,
and compared findings from animal models with those from human subjects. In human beings, the characteristic pathological features of Mp pneumonia
have been reported as alveolar infiltration with neutrophils and lymphocytes and lymphocyte/plasma cell infiltrates in the peri-bronchovascular area.
Herein, we demonstrated the novel aspects of Mp pneumonia that the severity of the Mp pneumonia seemed to depend on the host innate immunity to the Mp,
which might be accelerated by antecedent Mp exposure (re-exposure or latent respiratory infection) through up-regulation of Toll-like receptor 2 expression
on bronchial epithelial cells and alveolar macrophages. The macrolides therapy might be beneficial for the patients with macrolide-resistant Mp pneumonia
via not bacteriological but immunomodulative effects. This exhaustive review focuses on pathogenesis and extends to some therapeutic implications
such as clarithromycin, and discusses the various diverse aspects of Mp pneumonia.
It is our hope that this might lead to new insights into this common respiratory disease.

Fatal Disseminated Cryptococcosis Resembling Miliary Tuberculosis in a Patient with HIV Infection.

Shimoda M , Saraya T, Tsujimoto N, Kurai D, Takizawa H, Goto H.

Intern Med. 2014;53(15):1641-4. Epub 2014 Aug 1

Abstract
A 51-year-old man was transferred to our hospital due to acute respiratory failure that had progressed over four days.
A chest X-ray and thoracic computed tomography scan showed multiple faint micronodules randomly distributed throughout
both lungs with ground glass opacity, suggesting miliary tuberculosis or Pneumocystis jirovecii pneumonia with acute respiratory distress syndrome.
Six hours after admission, the patient died of septic shock. Later, the cryptococcal antigen titer was found to be markedly elevated (1/65,536),
with a positive result for anti-human immunodeficiency virus and a low CD4 cell count (12/μL).
The present case is reminder that disseminated cryptococcosis with HIV infection can be misdiagnosed as miliary tuberculosis based on radiological findings.

BMJ Case Rep. 2014 Jun 10;2014. pii: bcr2014204691. doi: 10.1136/bcr-2014-204691.

Three stripes sign: muscle involvement with internal fibrosis in a patient with sarcoidosis.

Tsujimoto N, Saraya T, Shimoda M, Goto H.

REVIEW ARTICLE Front. Microbiol., 26 May 2014 | doi: 10.3389/fmicb.2014.00226

Epidemiology of virus-induced asthma exacerbations: with special reference to the role of human rhinovirus
Takeshi Saraya1, Daisuke Kurai1, Haruyuki Ishii1, Anri Ito1, Yoshiko Sasaki2, Shoichi Niwa2, Naoko Kiyota3, Hiroyuki Tsukagoshi2, Kunihisa Kozawa2, Hajime Goto1 and Hajime Takizawa1*

1Department of Respiratory Medicine, School of Medicine, Kyorin University, Mitaka, Tokyo, Japan

2Gunma Prefectural Institute of Public Health and Environmental Sciences, Gunma, Japan

3Kumamoto Prefectural Institute of Public Health and Environmental Sciences, Kumamoto, Japan

Viral respiratory infections may be associated with the virus-induced asthma in adults as well as children.
Particularly, human rhinovirus is strongly suggested a major candidate for the associations of the virus-induced asthma.
Thus, in this review, we reviewed and focused on the epidemiology, pathophysiology, and treatment of virus-induced asthma with special reference on human rhinovirus.
Furthermore, we added our preliminary data regarding the clinical and virological findings in the present review.

Research article

Mechanic's hands revisited: is this sign still useful for diagnosis in patients with lung involvement of collagen vascular diseases?

Erei Sohara, Takeshi Saraya, Shinji Sato, Naoki Tsujimoto,
Takayasu Watanabe, Saori Takata, Yasutaka Tanaka, Haruyuki Ishii,
Hajime Takizawa and Hajime Goto

BMC Research Notes 2014, 7:303 doi:10.1186/1756-0500-7-303

Background
The presence of "mechanic's hands" is one of the clinical clues for collagen vascular diseases.
However, the exact relevance of "mechanic's hands" in collagen vascular diseases has not been well documented.
The aim of this study was to clarify the relevance of "mechanic's hands" to collagen vascular diseases
including various skin lesions and interstitial pneumonia.

Methods
A retrospective review of the medical records of patients with "mechanic's hands" at our hospital
between April 2011 and December 2012 was conducted. A PubMed search was also conducted using the term "mechanic's hands".

Results
Four patients in our institution and 40 patients obtained from PubMed who had "mechanic's hands" were identified.
The most frequent diseases were DM/amyopathic DM (n = 24, 54.5%) and anti-ARS syndrome (n = 17, 38.6%). In these patients,
the major skin lesions associated with "mechanic's hands" were periungual erythema (n = 23, 52.3%),
Gottron's sign (n = 17, 38.6%), heliotrope rash (n = 10, 22.7%), Raynaud's phenomenon (n = 9, 20.5%),
and anti-ARS syndrome (n = 17, 38.6%). Six cases (2 DM, 4 anti-ARS syndrome) had only "mechanic's hands".
Antibodies to anti-ARS (n = 24) were Jo-1 (n = 19), PL-7 (n = 3), OJ (n = 1), and PL-12 (n = 1).

Conclusion
The presence of "mechanic's hands" together with diverse skin lesions could be a clinical clue to the diagnosis of
lung involvement associated with collagen vascular diseases, especially in anti-ARS syndrome or DM/amyopathic DM.

Breakthrough invasive Candida glabrata in patients on micafungin: A novel FKS gene conversion correlated with sequential elevation of minimum inhibitory concentration.

J Clin Microbiol. 2014 Apr 30. [Epub ahead of print]

Saraya T1, Tanabe K, Araki K, Yonetani S, Makino H, Watanabe T, Tsujimoto N, Takata S, Kurai D, Ishii H, Miyazaki Y, Takizawa H, Goto H.

Abstract
The Candida glabrata strains sequentially isolated from blood developed micafungin-resistance from <0.015 to 4 μg/mL of minimum inhibitory concentrations.
A novel mutation, 262 bp of FKS2 (containing F659del) was converted to the homologous region in FKS1, was identified in micafungin-resistant strains.
PMID: 24789192

Community‐acquired Pseudomonas aeruginosa pneumonia in previously healthy patients

Shingo Tsuji1, Takeshi Saraya1⇑, Yasutaka Tanaka1, Hiroshi Makino2, Shota Yonetani2, Koji Araki2, Daisuke Kurai1, Haruyuki Ishii1, Hajime Takizawa1 and Hajime Goto1

JMM Case Reports 2014 1.  Published online 2014.
doi: 10.1099/jmmcr.0.000281

Sudden multiple fractures in a patient with sarcoidosis in multiple organs.

BMJ Case Rep. 2014 Apr 7;2014. pii: bcr2013201408. doi: 10.1136/bcr-2013-201408.

Sada M1, Saraya T, Ishii H, Goto H.

Abstract
A 30-year-old man who incidentally fractured his right olecranon and other multiple phalanges was admitted to our hospital.
He had a 2-year history of uveitis and bilateral hilar lymphadenopathy (BHL), and pulmonary sarcoidosis was diagnosed
from transbronchial lung biopsy. Right elbow arthrodesis was performed, and biopsied specimens showed non-caseating epithelioid cell granuloma,
suggesting osseous sarcoidosis. He was discharged uneventfully without further treatment,
but BHL had progressed with the appearance of lung parenchymal lesions 3 months later. At that time,
involvement of other organs was also noted on Gallium-67 scintigraphy, showing accumulations in BHL,
axillary and inguinal lymph nodes, enlarged liver and spleen and subcutaneous areas.
After initiation of steroid therapy, multiple organ involvement improved, and no further bone involvement has been recognised to date.
Osseous sarcoidosis complicated by bone fracture is an extremely rare presentation, but should be considered in patients with sarcoidosis,
especially when multiple organs are involved.
PMID: 24711466 [PubMed - in process]

Antemortem diagnosis with multiple random skin biopsies and transbronchial lung biopsy in a patient with
intravascular large B-cell lymphoma, the so-called Asian variant lymphoma

BMJ Case Reports 2014; doi:10.1136/bcr-2013-202661


Tomotaka Nishizawa, Takeshi Saraya, Haruyuki Ishii, Hajime Goto


Summary
A 59-year-old, previously healthy man presented to our hospital, with a 3-month history of high fever,
nocturnal sweating and exertional dyspnoea. Aggressive diagnostic procedures such as multiple random skin biopsies
and transbronchial lung biopsy (TBLB) led to an antemortem diagnosis of intravascular large B-cell lymphoma (IVLBCL),
which showed abundant CD20 atypical lymphocytes aggregated in lumina of small vessels. The 29 cases diagnosed with IVLBCL
during their lifetime by TBLB were reviewed. Their clinical features included respiratory symptoms
(hypoxaemia, dyspnoea and dry cough) and persistent fever. IVLBCL patients show various radiological patterns
(ground glass opacities, multiple centrilobular nodules, interlobular septal thickening, interstitial shadows
and thickening of bronchovascular bundles), suggesting lymphatic or haematological spread.
Antemortem diagnosis of IVLBCL is difficult, but a multidisciplinary approach, with aggressive multiple random skin biopsies
and/or TBLB, should be considered in patients with respiratory symptoms that are refractory to antibiotics or prednisolone treatment.