A Case of Adrenocortical Adenoma Causing Cushing's Syndrome with Contralateral Nonfunctioning Adenoma / 대한내분비학회지

We report the case of a 43-year-old woman with Cushing's syndrome showing bilateral adrenococortical adenomas. We performed bilateral selective adrenal vein samplings. Hypersecretion of cortisol on the left sided adrenal tumor was observed, but no evidence of cortisol hypersecretion from the adrenal tumor on the right side was observed. The left adrenal tumor was resected selectively, but the right adrenal gland was reserved. The left adrenal tumor was histologically diagnosed as a adrenal adenoma without any evidence of nodular hyperplasia. Following the resection of the left adrenal gland, no cortisol hypersecretion from the remaining adrenal tumor on the right side was observed until now, suggesting that a selective adrenalectomy of functioning adenoma may be an acceptable treatment modality.

Hepatic Injury during Treatment with Antithyroid Drugs in Patients with Hyperthyroidism / 대한내분비학회지

BACKGROUND: Propylthiouracil (PIV) and methimazole (MMI) were widely used for the treatment of hyperthyroidism. Hepatic injury caused by these agents is a rare but serious complication. This study is to investigate the clinical features of hepatotoxicity from antithyroid drugs. METHODS: We reviewed 17 cases of hepatic injury during treatment with antithyroid drugs in patients with hyperthyroidism. Included were 6 cases we experienced and 11 cases reported in Korean literature from 1986 to 1999. We analyzed the clinical features of hepatic injury. RESULTS: Of 17 cases of hepatic injury, 12 were PTU cases and 5 MMI cases. The mean age of PTU cases was 40 years with 6/12 patients over 40 years old and 2/5 MMI cases were over 40 years old. The dose of PTU was 300 mg/d or more in 10/12 cases (83%) and the dose of MMI was 30 mg/d in 3/5 cases (60%). The hepatic injury occurred within 3 months in 8/12 PTU cases (67%) and within 2 months in 4/5 MMI cases (80%). The duration of hepatic injury tended to be longer in MMI cases than in PTV cases (median; 80 vs 41 days, p=0.102). In PTU cases, the duration of hepatic injury was correlated with the duration of drug use before hepatic injury (p<0.05). All of 8 biopsied cases who took PTU had predominantly hepatocellular necrosis. Two biopsied cases who took MMI had cholestatic jaundice and nonspecific abnormality, respectively. Biochemical findings of all MMI cases were compatible with cholestatic jaundice. As to the treatment of hyperthyroidism after hepatic injury, 4/12 PTU cases were treated with RAI therapy, 5 with MMI and one with surgery, and treatment was unknown in two. On the other hand 3/5 MMI cases interestingly entered into spontaneous remission after hepatic injury and 2/5 had RAI therapy. Hepatic dysfunction recurred in each one whom treatment by changing to MMI or PTU was tried on. CONCLUSION: Most of hepatic injury during treatment with antithyroid drugs developed within two to three months of drug use. The hepatic injury related to PTU was mainly cytotoxic whereas that related to MMI was cholestatic. Since there is a cross-reaction between PTU and MMI in hepatotoxicity, RAI therapy or operation shoud be considered as an alternative treatment of hyperthyroidism after hepatic injury.

Successful Hemodialysis in Acute Phenobarbital Intoxication / 대한신장학회잡지

Phenobarbital is one of long-acting barbiturate with low lipid solubility and used frequently as an anticonvulsant. However, in severe intoxication, hypotension and respiratory arrest are the major causes of prehospital mortality. Mortality is 3M for blood levels over HO pg/mL and estimated lethal adult dose is 6-10g. No effective antidotes are available. We report a case of phenobarbital intoxication in a 29-year-old female, treated successfully with hemodialysis. She was found corhatose on the day of admission and was alleged to have taken 30g of phenobarbital. On physical examination, the blood pressure was 80/60mmHg, and pulse, 97/min. There was no respiration. Pupil was dilated fully. Corneal and deep tendon reflexes were absent. There was no response to painful stimuli. She was treated conservatively with mechanical ventilation, gut decontamination and forced diuresis. Hemodialysis was tried to remove excess phenobarbital for 13 hours. The blood phenobarbital level at admission was 162.2 pg/ mL, which was decreased to 114.4pg/mL after first session of hemodialysis. On the fifth hospital day, blood level decreased to 41.8 pg/mL and she regained her consciousness. She was discharged on the 10th hospital day without major sequelae.

A Case of Endoscopic Drainage of Pancreatic Abscess with Biliary Stent / 대한내과학회지

Pancreatic abscess is a highly lethal infectious complication of acute pancreatitis despite a wide variety of operative approaches and percutaneous drainage for the treatment. Surgical drainage has its limitation because of high postoperative mortality, recurrence, operative hemorrhage and/or gastrointestinal fistula. Percutaneous drainage has been used only as a temporizing measure prior to operation in critically ill patient or as additional modality for a postoperative recurrent abscess. Endoscopic drainage can be indicated as a primary therapy for the well-localized paraintestinal pancreatic abscess bulging into the duodenal or gastric lumen, as it has been proven successful in patients with pancreatic pseudocyst compressing duodenum or stomach. However, the report is rare. We report a case of pancreatic abscess successfully treated with endoscopic drainage without any complications.

A Case of Antinuclear Antibody(ANA) Negative Lupus Nephritis / 대한신장학회잡지

Systemic lupus erythematosus is a multisystemic autoimmune disease in which the kidneys are frequently involved. Clinical diagnosis of SLE is based on the criteria of American Rheumatism Association (ARA). A few cases who were classified as SLE by the ARA criteria but were antinuclear antibody (ANA)-negative have been reported. It was reported that critical factor in ANA positivity is the choice of substrate. It is generally accepted that the cultured cell of human origin, especially HEP-2 cell, is better than tissue section or animal cells. Thus, the ANA test is negative only in approximately 2M of SLE patients when human tissue culture cells are used as substrate. We report a 25-year-old man admitted to our hospital because of generalized edema. He was found to have active lupus nephritis(WHO class IV), photosensitivity and pancytopenia. The result of FANA test which used HEP-2 cell as substrate was repeatedly negative, but anti-ds DNA and anti-Ro antibody were positive.

Two Cases of Severe Neutropenia Associated with Ticlopidine

Ticlopidine is a powerful inhibitor of platelet aggregation which is induced by adenosine diphosphate. Ticlopidine has been shown to be effective in reducing combined stroke, myocardial infarction, reocclusion of coronary stent. The principal side effects of ticlopidine are severe neutropenia, rash and gastrointestinal upset. Recently, we experienced two cases of severe neutropenia associated with ticlopidine. One was administered ticlopidine to prevent subacute thrombosis after intracoronary stent implantation in unstable angina pectoris. Thirty days of therapy, her absolute neutrophil count (ANC) had dropped to 14/mm3 . The other patient was presented with recurrent episodes of cerebral infarction, for which he had undergone right carotid angiogram. The carotid angiogram demonstrated tight stenosis of right internal carotid artery. Carotid artery stenting was performed at right internal carotid artery without any complications. Twenty seven days of ticlopidine therapy, his ANC had dropped to 111/mm3. The ticlopidine was stopped, and they were given granulocyte-colony stim-ulating factor 250 microgram/day subcutaneous injection until their ANC was up to 1000/mm3. They were discharged with normal neutrophil count and no other complications.

A Case of Acute Respiratory Distress Syndrome with Pulmonary Embolism induced by Injection of Silicone at Vaginal Wall / 결핵

Silicone fluid(polydimethylsiloxane) is widely used in breast augmentation and other cosmetic procedures because of little incidence of complications and low mortality rate. However, local reaction following silicone injections can be occurred sometimes leading to serious complications. Especially, illicit silicone injections have resulted in severe reactions within the pulmonary area, and some have resulted in acute respiratory distress syndrome subsequently. We experienced a case of acute respiratory distress syndrome induced by subcutaneous injections of silicone at vaginal wall. The patients was 39-year-old, previously healthy woman who had complained of dyspnea related to silicone injection at vaginal wall. Chest X-ray and chest CT scan show diffuse air consolidation with ground glass opacities and perfusion lung scan revealed likelihood of pulmonary embolism as showing multiple perfusion defects. We report a case of acute respiratory distress syndrome after silicone injection with review of literature.