Volume 91  ·   Issue 23  ·  2011

The shoulder and elbow arthroscopy technology in China has just started in the early 1990s. After the hard work of several generations, the number of operations has increased year by year, and the related research has been deepened step by step, and great progress has been made. The development of shoulder and elbow arthroscopy is still unbalanced. Although many hospitals have the corresponding equipment, they have not yet carried out related business, and the technical level of the practitioners needs to be further improved. Therefore, it is not neglectable to strengthen the clinical and basic research of shoulder and elbow arthroscopy minimally invasive surgery and catch up with the international advanced level.

Objective To explore the preliminary results of lateral ulnar collateral ligament (LUCL) reconstruction or repair for posterolateral rotatory instability (PLRI) of elbow.Methods Between December 2006 and September 2010, 9 consecutive patients (9 elbows) undergoing surgical reconstruction or repair of LUCL for the treatment of elbow PLRI were studied.Surgical reconstruction of LUCL was performed with a tendon graft in 6 elbows and reattachment of LUCL to humerus in 3.The mean patient age was 28 years (range: 17-48). All patients had a previous history of elbow injury.Among them, 6 had a history of elbow dislocation.The average duration of symptoms was 10.7 months (range:5 days-30 months).The outcomes were graded with respects to objective and subjective stability, pain and range of motion as defined by Nestor.Results All patients were followed up.The mean follow-up period was 20 months (range:4-49). Postoperatively, no patient had residual instability or a positive pivot shift test in elbow.Their outcomes were graded as excellent (n=6), good (n=2) and fair (n=1).Subjective assessment revealed that all were satisfied with their surgical outcomes.Conclusion An accurate recognition of PLRI of elbow is important for its appropriate management. Tendon graft is recommended for the reconstruction of LUCL.Surgical ligament reconstruction or repair is the preferred treatment option for restoring normal functions and elbow stability.Further studies are warranted because of a limited number of patients in the present study.

Objective To evaluate the combined tenodesis for long head of bicep tendon lesion with massive rotator cuff tear.Methods From January 2004 to June 2009, 41 patients of long head of bicep tendon lesion with massive rotator cuff tear were treated by arthroscopy.The follow-up period was over 12 months.There were 19 males and 22 females with an average age of 57±11 year old.All patients were treated by arthroscopy with double row technique for rotator cuff tear repair and tenodesis for lesions of long head of bicep tendon.It combined the long head of bicep tendon with anterior edge of rotator cuff. The mean visual analogue scale (VAS) was 5.1±23, the range of forward flexion (100±55)°, external rotation (27±24)° and internal rotation up to T12 (T5-S1) level pre-operation on average.The Constant-Merly score was 50±23, the University of California at Los Angeles (UCLA) score 14±6 and the simple shoulder test (SST) score 4.0±2.7 pre-operation on average.The strength of flexed elevation was (17±20)% and strength of elbow flexion (101±16)% versus the other side.Results All patients healed without any complication.Their outcomes improved significantly (P<0.01).The mean VAS score improved to 1.5±1.8, forward flexion (155±21)°, external rotation (37±24)° and post-operative internal rotation up to T10 (T4-L3) on average.The mean Constant improved to 87±13, mean UCLA 29±5 and mean SST 9.3±2.4.The strength of flexed elevation recovered to (68±21)% post-operation. Significant differences were found in range of motion, VAS, strength and functional score (P<0.01).No difference was observed for Mayo elbow performance score (MEPS) and elbow flexion strength at pre-operation versus post-operation.Conclusion The combined tenodesis with double row rotator cuff repair is an effective approach for treating lesion of long head of bicep tendon with massive rotator cuff tear.

Objective To compare the clinical outcomes of modified Dewar method versus arthroscopic double Endobutton fixation technique for the treatment of acute acromioclavicular joint dislocation (Rockwood types Ⅲ-Ⅴ).Methods All cases with acute acromioclavicular joint dislocation (Rockwood types Ⅲ-Ⅴ) were treated at our department from October 1997 to October 2009.Among them, 28 cases undergoing modified Dewar method were followed up.There were 20 males and 8 females aged 18-68 years old with a mean follow-up period of 6.8 years.And the arthroscopic technique of Endobutton fixation was employed for another 24 cases.There were 19 males and 5 females aged 19-65 years old with a mean follow-up period of 1.5 years.The radiographic findings, clinical outcomes and complications of two groups were compared.Results The good/excellent rate of modified Dewar group and arthroscopic double Endobutton group were 92.8% and 95.8% respectively.There was no significant difference between two groups.No significant difference existed between two groups as to the VAS (visual analogue scale) pain score and UCLA (University of California at Los Angeles) score.The modified Dewar group had a higher rate of ectopic ossification in coracoclavicular ligament than that of the arthroscopic double Endobutton group (25% vs 8.33%).Yet there was no statistical significance.However, the distance between clavicle and coracoid process was larger in the modified Dewar group (11.96 vs 8.54 mm, P<0.05).Conclusion Both modified Dewar method and arthroscopic double Endobutton fixation technique are both efficient therapies for acute acromioclavicular dislocation (Rockwood types Ⅲ-Ⅴ). The former tends to be more invasive while the latter can better maintain the relationship of corocoid process and clavicle.

Objective To explore the effects of DNA methylation of microRNA (miRNA) gene on their expressions in patients with gastric carcinoma.Methods A total of 80 subjects were divided into gastric carcinoma group(n=40)and control group(n=40).The DNA methylation status of miRNA-34b/c and miRNA-124a gene promoters was detected by DNA methylation specific polymerase chain reaction (MSP) in gastric carcinoma tissues and normal mucosal tissues.Results The positive rate of DNA methylation of miRNA-34b/c gene promoter was 77.5%(31/40)and 5.0%(2/40)in gastric carcinoma and control groups respectively.There was statistically significant difference between two groups (P<0.05). The positive rate of DNA methylation of miRNA-124a gene promoter was 60.0%(24/40)and 0 in these two groups respectively.There was statistically significant difference between two groups (P<0.05).Also the hypermethylation positivity of gene promoter of miRNAs was correlated with the clinicopathological features of gastric carcinoma.Conclusion The hypermethylation of miRNA-34b/c and miRNA-124a gene promoters may play a crucial role in the occurrence and development of gastric carcinoma.

Objective To explore the differential diagnosis and pertinent treatment of women with right lower quadrant abdominal mass.Methods The clinical data of 25 women patients with appendiceal mucocele at our hospital from 2000 to June 2010 were recorded.And their clinical presentations, auxiliary examinations and treatment were analyzed retrospectively with the SPSS17.0 software.Results Among 1157 women undergoing appdicelectomy at our hospital, 25 (2.16 %) had appendiceal mucocele.Their mean age was 58.2 years old.Their presenting symptoms and signs were non-specific.Ten cases (40%) were misdiagnosed as adnexal mass.The mass could be palpable by pelvic examination in 80% cases while 66.7% by abdominal examination.For preoperative auxiliary examination, the correct rate of ultrasonogram was 54.2% and CT 60%.The positive rate of carcinoembryonic antigen (CEA) was 57.1% while that of carbohydrate antigen 19-9 (CA199) 18.2%.Neither had statistical significance.There were three pathological entities: mucinous cystadenoma, malignant mucinous cystadenocarcinoma and simple retention mucoceles.Because of incidental discovery, the treatment remained variable.The approaches included appendectomy, cecectomy, right hemicolectomy and debulking according to the frozen pathological examination.Conclusion As a rare condition, appendiceal mucocele is usually misdiagnosed as right adnexal lesion.Because of its anatomic position, it should be considered in the differential diagnosis of adnexal masses.Auxiliary examinations such as ultrasonogram, computed tomography and serum CEA may be helpful for its diagnosis.Its optimal management is achieved through an accurate preoperative identification and subsequently careful resection.

Objective To study the diagnostic value of anti-cyclic citrullinated peptide antibody (anti-CCP) and magnetic resonance imaging (MRI) of metacarpophalangeal joints(MCP)and wrist in early rheumatoid arthritis(RA).Methods MRI of MCP and wrist joint, laboratory indices of anti-CCP and rheumatic factor (RF) were performed and recorded in the 94 early-stage RA patients, 24 non-typical monoarthritis and 35 other arthritis.The MRI findings and OMERACT (outcome measures in rheumatoid arthritis clinical trials) score were analyzed in comparison with their clinical and laboratory indices.Results The sensitivity of anti-CCP, synonitis, bone erosion and bone erosion was 55.3%, 100%, 25.5% and 88.3% respectively in early-stage RA patients.The specificity was 88.6%, 71.4%, 94.3% and 65.7% respectively.There was significant difference between early-stage RA group and other arthritis group (P<0.05). Bone erosion was found to be the most specific among MRI findings.And bone erosion of wrist joint had a positive correlation with anti-CCP.MRI was a more efficient supplemental modality in diagnosing early-stage RA as compared with conventional radiological films.Among 94 early-stage RA, their MRI findings and OMERACT scores of wrist joint appeared more obvious.Conclusion Anti-CCP has a better specificity for early-stage RA than RF. But MRI may visualize the disorder of RA earlier while it is often missed by radiological films.Both have prominent diagnostic values in early RA patients. Bone erosion of wrist joint has a positive correlation with anti-CCP.MRI may help to differentiate those RA patients with negative anti-CCP.

Objective To investigate the value of high frequency and color Doppler ultrasonography in detection of synovitis and the intra-articular vascularization in the knee joint of patients with newly-diagnosed rheumatoid arthritis (RA).Methods Forty-one patients (30 women, 11 men) with newly-diagnosed RA were recruited to a cross sectional study(RA group).Forty-one age and gender-matched healthy volunteers were used as control group.The thickness of hydatid fluid, synovium hyperplasia, color flow imaging, peak systolic velocity(PSV), end diastolic velocity(EDV), resistance index(RI), venous blood flow and intra-articular perfusion were evaluated by high frequency and color Doppler ultrasonography.Results Totally 91.46% knee joints with synovial hyperplasia(>2 mm) were found in 41 patients with RA(75/82 knee joints),and the thickness of the synovial membrane was 2.2-19.7 mm (average 6.3±3.4 mm). In aspect of blood flow,the percentage of 0 to 3 grade were 18.67%(14/75), 29.33%(22/75),45.33 %(34/75) and 6.67%(5/75), respectively;the results of arterial blood were indicated with PSV (10.82±3.71 cm/s),EDV(3.86±1.12 cm/s)and RI (0.61±0.07),while the average of venous blood velocity was 2.72±1.02 cm/s.Joint effusion was found in 69 joints (84.15%)with the anteroposterior diameter 2.4-16.1 mm( average 6.9±3.2 mm).The thickness of synovial membrane was 1.2-1.8 mm (average 1.4±0.4 mm) and no significant difference were observed in joint effusion, signal of blood flow and thickness of synovial membrane in the control group.Conclusions High frequency and power Doppler ultrasonography may be a valuable and optimal clinical tool to accurately and objectively detect synovial hyperplasia, vascular pannus formation and joint effusion in the knee joint of patients with RA

Objective To compare the efficacy of cardiovascular MRI and DSA in stent-treatment selection for patients with carotid atherosclerosis.Methods Forty-six patients with carotid plaque detected by ultrasound were enrolled in this study.Carotid plaque MRI and DSA was performed.Images were evaluated for luminal stenosis(NASCET standard), fibrous cap rupture, intra-plaque hemorrhage and calcification.Kappa value and paired chi-square test were used for the statistical analysis.Results These 92 carotid arteries were divided into two groups, that were the symptomatic artery group with 25 vessels and asymptomatic artery group with 64 vessels, and the other 3 arteries were excluded due to stent placement.There was good concordance between the degree of stenosis measured by MRI and DSA (Kappa value 0.882).There was significant difference in detecting FC rupture by two modalities (P<0.01).As to the indication selection for stent treatment by two modalities, there was significant difference for asymptomatic group(22 vessels by MRI and 14 vessels by DSA, P<0.05), neither did the symptomatic group.There were two patients, among those 14 who underwent the stent treatment, that decided stent treatment only rely on the FC rupture detected by MRI.Furthermore, MRI detected 37 vessels with intra-plaque hemorrhage and 71 vessels with calcification in the plaque.Conclusion MRI was much more suitable for the selection of stent treatment for patients with carotid atherosclerosis as compared with DSA.

Objective To explore the significance of sleep problems in the diagnosis of depressive and anxiety disorders.Methods A cross-sectional study was conducted through stratified convenient sampling in outpatients at our hospital from November 19, 2009 to January 19, 2010.A total of 203 outpatients (≥16 years old) were recruited from Department of Internal Medicine, Department of Surgery, Department of Obstetrics & Gynecology and other departments.Sleep Questionnaire was used as a screening tool for depressive and anxiety disorders.Composite international diagnostic interview (CIDI) was conducted by trained interviewers.According to diagnostic and statistical manual of mental disorders, Fourth Edition (DSM-Ⅳ) using the outcome from the logistic diagnostic procedure of CIDI as a golden standard for depressive and anxiety disorders, the validities of Sleep Questionnaire were calculated.Results According to the Sleep Questionnaire, the 12-month prevalence of any sleep problem was 31.0% (63/203). The Cronbach′s α coefficient of the questionnaire was 0.764 and the area under the ROC (receiver operating characteristic) curve 0.741.With a cut-off point of 1, the sensitivity was 68.0% and the specificity 74.2% respectively.And it achieved the best composite diagnostic capacity.The positive predictive values were at least 27.0%.Conclusion Sleep problem is a common complaint at a general hospital.When the duration and severity of sleep problem meet the standards of Sleep Questionnaire, a physician should be aware of possible depressive and anxiety disorders and more detailed information should be collected.

Objective To investigate the clinical, neuropsychological, neuroimaging features and treatment of dementia with Lewy bodies (DLB).Methods The clinical, neuropsychological, neuroimaging and therapeutic features of 33 DLB patients were retrospectively analyzed.Results There were 25 males and 8 females.The mean course from onset to diagnosis was 3.3 years.Sleep disorder, depression, anxiety and constipation were present at 1-10 years prior to DLB onset in 10 patients.Memory impairment (52%) and parkinsonism (21%) were initial symptoms.The mean duration from memory impairment to presence of parkinsonism was 17 months.Pattern of extrapyramidal signs showed bilateral, symmetry and axial muscles bias as postural instability and facial impassivity, tremor was less in DLB.Hallucination (70%), sleep disorder (63%), apathy (56%) and delusion (52%) were the major behavioral and psychological symptoms.Hallucination occurred within a mean of 15 months after presence of initial symptoms.Cognition impairment progressed rapidly in half of patients.Neuropsychological tests of mild patients revealed visuospatial dysfunction and relatively preservation of memory.Severe impairment of all domains of cognition was noticed in moderate-severe patients.MRI (magnetic resonance imaging) revealed the preservation of hippocampal structures.And PET (positron emission tomography) showed hypometabolism of occipital lobe.Cholinesterase inhibitors could improve cognitive impairment and behavioral symptoms in a large majority of patients.Conclusion Neuronal dysfunction may be present at an early stage of DLB. Early presence of hallucination, a high prevalence of sleep disorders, axial rigidity and hypometabolism of occipital lobe on PET may help to distinguish DLB from other types of dementia.

Objective To evaluate the effects of PRL-3 siRNA (small interfering RNA) on the migration of endometriotic stromal cells.Methods Primary endometriotic stromal cells were cultured in vitro.Then PRL-3 (phosphatase of regenerating liver-3) siRNA was transfected to silence the PRL-3 gene.And the PRL-3 protein expression was analyzed by Western blot.The changes of cell migration were detected by cell pseudopod formation, scratch test and transwell cell migration test.Results The expression of PRL-3 protein significantly decreased in the experimental group versus two other control groups (P<0.05).The formation of cell pseudopod was much less in experimental group than that in control groups. Within the same time, the number of migration cells was 0.87±0.21 in experimental group.It was less than 1.75±0.28 in blank control group and 1.63±0.39 in negative control group(P<0.05).Conclusion PRL-3 siRNA can down-regulate the PRL-3 gene and decrease the migratory capacity of endometriotic stromal cells.And PRL-3 may be a promising target in the therapeutics of endometriosis.

Objective To evaluate the microsurgical treatment for sylvian fissure arteriovenous malformations (AVMs).Methods The clinical data of 94 sylvian fissure AVMs treated microsurgically was retrospectively collected.They were classified as medial, lateral, deep, anterior and simple AVMs according to the anatomic location of nidus in sylvian fissure.Results Total lesion removal was achieved in all patients and it was confirmed by postoperative digital subtraction angiography. Transient neurological deficits, including slight hemiparesis (n=5, 5.3%) and aphasia (n=4, 4.3%), were documented.Another 2 patients (2.1%) presented with a postoperative epidural and an intracranial hematoma respectively. However, an excellent outcome was observed in all patients as indicated by the Karnofsky performance scale >90.Conclusion The microsurgical treatment for sylvian fissure AVMs has been greatly restrained by the involvement of multiple brain functional regions and its anatomic complexity. A more aggressive approach is recommended.

Objective To investigate the relationship of the imbalance of CD4+T cell subgroups and the pathogenesis of ulcerative colitis (UC).Methods Peripheral blood samples were collected from 24 UC patients and 17 healthy donors.Then the phenotype of CD4+T cells and the major transcription factor expression of each subset were analyzed by flow cytometry and real-time PCR (polymerase chain reaction) respectively.The serum concentrations of major cytokines of each subgroup were measured by cytometric bead array (CBA) and ELISA (enzyme-linked immunosorbent assay).Results (1) The proportion of Treg cells in the UC group was lower than the control group (6.7%±1.7% vs 7.9%±1.4%, P=0.016), especially in active stage (6.4%±1.7%, P=0.005). As compared with the control group, the expression of FOXP3 mRNA was lower in the UC Group (P=0.020). And so was the serum concentration of TGF-β1 [(21±8) μg/L vs (28±7) μg/L, P=0.026].(2)There were no significant differences in Th1-related transcription factors and cytokines between two groups.(3) Th2 cells were higher in the UC group (2.7%±1.1% vs 1.6%±0.4%, P=0.002), especially in active stage (2.8%±1.0%, P=0.001).The expression of GATA-3 mRNA was 4.4 folds higher than that of the controls (P=0.045).(4) Th17 cells were higher in the UC group (3.4%±1.8% vs 1.8%±0.7%, P=0.005). And the RORγt mRNA expression was 13 folds higher in UC group (P=0.001); the serum concentrations of IL-6 and IL-17 were higher in the UC group (both P<0.05). (5) The ratios of Treg/Th2 and Treg/Th17 were significantly lower in the UC group and associated with disease activity (both P<0.05).Conclusion The imbalances of Th2, Treg and Th17 subgroups may play pivotal roles in the pathogenesis of UC.

Objective To evaluate the osteogenic functions of injectable biological bone cement during repairing inclusive bone defects in rabbit femoral condyles.Methods Encapsulated rhBMP-2 gene modified rabbit bone mesenchymal cells (BMSCs) were seeded into calcium phosphate cement (CPC) to prepare injectable biological bone cement.The live/dead cell ratio was detected by calcein-AM/ethidium homodime staining and cement microstructure examined by electron microscope.The anti-compression strength of CPC were tested.Inclusive bone defects were created in the bilateral femoral condyles of 6 rabbits.The biological CPC was implanted randomly at one side and pure CPC at the other side.The radiological films were taken immediately, at Weeks 6 & 12 post-operation.The animals were sacrificed at Week 12 post-operation and both femoral condyles were retrieved to prepare decalcified slides.The morphometrologic parameters of bone tissue, such as cement area (CA), calcified trabecular area (TBA), osteoblast index (OBI) and osteoclast (OCI) were measured.Immunohistochemical staining was performed to detect the expressions of BMP (bone morphogenetic protein)-2, TGF (transforming growth factor)-β1 and VEGF (vascular endothelial growth factor).Results The calcein-AM/ethidium homodimer staining showed that the live rate of encapsulated cells was over 90%.It was found under electron microscope that there was the formation of hydroxyapatite crystals and the presence of connective microporous structure.The anti-compression strength of biological cement was (20.19±1.75) MPa. And it was much less than that of pure CPC.Radiological study showed that both types of CPC could fill bone defects completely without gap.The biological CPC degraded a little faster.As demonstrated by decalcified slides, the cements were absorbed into numerous small blocks around newborn trabecule without insertion of fibrous tissues.CA decreased to 9.68% in biological CPC group and it was much less than 17.47% for pure CPC group.TBA was 58.75% in biological CPC group and it was much greater than 34.34% for pure CPC group.There was no significant difference in OBT and OCT between two groups.Immunohistochemical staining showed there were a large number of oval-shaped nuclear mast cells in biological CPC group.They were strongly positive for the expression of BMP-2. A moderate number of cells had a positive expression of TGF-β1 and VEGF.More positive cells were present in biological CPC group.Conclusion The introduction of BMP-2 into CPC renders CPC capable of bone induction.Thus CPC induce both the proliferation of BMSCs and the expressions of TGF-β1 and VEGF.The synergistic effects of these three factors accelerate the degradation of CPC.

Objective To study the effects of cerebellar fastigial nucleus (FN) electrical stimulation on telomerase reverse transcriptase expression and mitochondrial apoptotic pathway in rats with focal cerebral ischemia and reperfusion.Methods A total of 100 adult male Wistar rats were randomly divided into 3 groups: sham operation group, modeling group (2-hour cerebral ischemia, followed by 24, 48 & 72-hour reperfusion) and FN-stimulating group (electrical stimulation of FN for 1-hour one day before 2-hour cerebral ischemia, followed by 24, 48 & 72 -hour reperfusion).HE (hematoxylin and eosin) and TTC (triphenyl tetrazolium chloride) staining were used to observe the morphological changes in rat brain and measure the ischemic lesion volumes.The expressions of TERT (telomerase reverse transcriptase) and Bax were detected by immunohistochemical methods and apoptotic cells by TUNEL (terminal deoxynucleotidyl transferase dUTP nick end labeling).The co-expression of TERT and Bax was detected by immunofluorescence double-labeling plus laser confocal microscopy.Results The morphological changes in rat brain were less greater in the FN-stimulating group than those in the modeling group. And the size of the cerebral infarct was significantly smaller in the FN-stimulating group(78.1±2.9, 83.1±4.5, 83.7±4.8)than that in the modeling group(120.9±8.2, 137.0±4.2, 141.1±3.3)(P<0.05) at all reperfusion time points. As compared with the modeling group(16.1±2.7, 16.9±2.4, 11.6±3.5), the FN-stimulating group(31.1±3.5, 30.0±3.4, 18.9±3.3)had a significantly larger number of TERT-positive cells (P<0.05) and a significantly reduced number of TUNEL-positive cells (49.6±2.8, 67.0±3.7, 46.8±3.2 vs 40.2±3.1, 54.8±2.8, 37.3±2.4) (P<0.05). The number of Bax-positive cells at different reperfusion time points in the FN-stimulating group was not significantly different from those in the modeling group (P>0.05). TERT partially co-localized with Bax in the cytoplasm. The number of double-labeled cells was significantly higher in the FN-stimulating group than that in the modeling group(14.1±1.3, 12.9±2.4, 9.0±2.0 vs 8.2±1.1, 6.3±2.4, 6.0±2.9)(P<0.05).Conclusion The expression of TERT significantly increases after a stimulation of FN.TERT may bind to Bax and inhibit Bax-mediated apoptosis by suppressing the mitochondrial relocalization of Bax from cytosol.

In the 1960s to 1980s, Dandong City was a high incidence area of malaria, but the incidence rate showed a declining trend year by year. By the end of 1990s, the malaria epidemic situation in Dandong City changed to mainly local malaria cases. In 2005, Dandong City began the monitoring work of the National Malaria Surveillance Point, in order to further adjust and formulate the prevention and control measures of malaria in our city, and to better complete the malaria control measures<According to the goals and target requirements of China's Action Plan to Eliminate Malaria (2010-2020)>, the data of malaria surveillance from Dandong City from 2005 to 2010 are analyzed. The results are reported as follows.

The patient, a 17-year-old female, was admitted to Peking Union Medical College Hospital on February 21, 2010 due to muscle weakness for 7 years, repeated chest tightness and holding breath for 2 years, and another one month. The patient developed sore throat and fever after catching a cold 7 years ago, followed by muscle weakness in the limbs, difficulty squatting, difficulty raising both arms, no rash, myalgia and dysphagia. Creatine kinase (CK) was elevated in other hospitals, and electromyography showed myogenic damage. The pathology of muscle biopsy was in line with the changes of myositis, and polymyositis was diagnosed in children. After treatment with hormones and immunosuppressants (cyclophosphamide, methotrexate, azathioprine, leflunomide, etc. successively), the creatine kinase gradually decreased to normal. He could walk on a flat road, but could not go upstairs, and needed family care for his life. During the course of the disease, the disease was repeated several times, which could be relieved after adding hormones. Two years ago, he began to have repeated chest tightness and holding breath, and chest CT showed multiple pulmonary bullae and spontaneous pneumothorax. The symptoms could be improved after supportive treatment such as closed chest drainage.