Pericardial Amyloidosis Associated with Light-chain Myeloma / 대한내과학회지

Amyloidosis is characterized by the deposition of amyloid fibrils, which cause both functional and structural damage to organs. Cardiac involvement with amyloids is a common cause of secondary cardiomyopathy and leads to congestive heart failure. Pericardial amyloidosis usually occurs at the late or terminal stage of the disease after myocardial involvement, but it is extremely rare for pericardial amyloidosis to proceed with myocardial involvement. Here, we report a rare case of a 66-year-old patient with light-chain myeloma, who presented with pericardial effusion but no evidence of cardiomyopathy.

Hepatotoxicity of Combination Treatment with Leflunomide and Methotrexate in RA Patients / 대한류마티스학회지

OBJECTIVE: Leflunomide is the newest disease-modifying anti-rheumatic drug (DMARD) that is known to have an equivalent clinical efficacy and tolerability to methotrexate (MTX). Previous studies reported that a co-treatment with MTX and leflunomide can induce additive clinical improvements in RA patients. However, a previous study also demonstrated a reversible elevation of the transaminase levels in up to 63% of patients administered a combination treatment of leflunomide and MTX. This study examined the hepatotoxicity of a combination treatment of MTX and leflunomide. METHODS: From March, 2004, to February, 2006, 203 patients who had been treated in 3 rheumatology clinics, Goyang city, South Korea, were reviewed retrospectively. The data showed that 38.92% of patients scored higher than grade 1 hepatotoxicity and 6.90% of patients scored higher than grade 2 according to the NCI/NIH (National Cancer Institute/National Institutes of Health) Common Toxicity Criteria. RESULTS: The median onset time of hepatotoxicity was 5.91 months after treatment. Leflunomide administration was stopped in 39 patients due to several adverse reactions. Among the 39 patients, hepatotoxicity was observed in only 20.51%, suggesting that the hepatotoxicity was not more frequent than expected. Hepatotoxicity did not increase in proportion to the dose of leflunomide and MTX, age, gender, and disease activity. CONCLUSION: These results indicate that a combined treatment of leflunomide and MTX can be used safely by monitoring the liver enzyme, particularly in the first six months.

The Pulmonary Embolism Severity Index in Predicting the Prognosis of Patients With Pulmonary Embolism

BACKGROUND/AIMS: Many prognostic models have been developed to help physicians make medical decisions on treating patients with pulmonary embolism. Among these models, the Pulmonary Embolism Severity Index (PESI) has been shown to be a successful risk stratification tool for patients with acute pulmonary embolism. The PESI, however, had not been applied to patients with pulmonary embolism in Korea. METHODS: The patients included in this study were diagnosed by computed tomography at Inje University's Ilsan Paik Hospital between December 1999 and March 2007. Risk stratification for the patients was performed using the PESI. The mortality rate was calculated according to each PESI risk class. RESULTS: Of the 90 patients enrolled in this study, ten were assigned to PESI class I, 29 to PESI class II, 22 to PESI class III, eight to PESI class IV, and ten to PESI class V. The mortality rate after 30 days in each class was 0, 10.3, 9.1, 0, and 50% (p=0.0016), respectively, whereas the respective hospital mortality rate was 4.8, 13.8, 13.6, 12.5, and 50% (p=0.0065). The overall mortality was 9.5, 27.6, 31.8, 50.0, and 60%, respectively (p=0.0019). The mortality rate was significantly associated with the PESI class. CONCLUSIONS: The PESI class was found to be significantly correlated with the 30-day mortality rate, hospital mortality, and overall mortality. Our data indicate that the PESI can be used to predict the prognosis of patients with pulmonary embolism and in making medical decisions regarding the treatment of patients with pulmonary embolism.

A Case of Multicentric Reticulohistiocytosis Mistaken as Rheumatoid Arthritis / 대한류마티스학회지

Multicentric reticulohistiocytosis (MRH) is a rare disease affecting joints, skin and internal organs. Yet the cause is still unknown. In most cases, it can be misdiagnosed as rheumatoid arthritis or psoriatic arthritis before typical change in the skin emerges, and precise diagnosis is essential because it may become severe enough to transform and destroy the joints. Therefore, skin or synovial biopsy can confirm the existence of this disease. This particular patient is a 39-year-old male who had been treated for rheumatoid arthritis on a wrist and hand and transferred to this hospital when arthritic pain continued with erythematous papules and nodules on the hands, the outer rims of the ears, hands and elbows. The X-ray examination of both hands revealed multiple marginal erosion of proximal and distal interphalangeal joints and destruction of subchondral bones. periarticular osteoporosis and joint space enlargement is combined, but no new bones were seen to be formed. Biopsy of erythematous nodules on the dorsum of hands showed that an infiltrate histiocytes and multi-nuclear giant cells were aligned irregularly, and immunological chemical staining showed potential for being positive to PAS and CD68. To control pain and regulate activity of the disease, tracing observation and treatment were started from the outside with NSAID, hydroxycholoquine, MTX and prednisolone. A month of treatment did not improve arthritis and skin problems, and increased dose of MTX, prednisolone did improve arthritis a little but not skin problems. Treatment with infliximab (3mg/kg), a anti-tumor necrosis factor, is in progress, showing improvement in both conditions.

A Case of Rheumatoid Arthritis Presenting Initially as Atlantoaxial Subluxation / 대한류마티스학회지

We report here on a case of rheumatoid arthritis (RA) that progressed from the spine to the peripheral joints. In RA, the involvement of the cervical spine usually correlates with the progressive erosion of peripheral joints, such as the hand or foot, and the elevation of disease activity. Generally, it takes over 2 years of rheumatoid involvement of the cervical spine to cause laxity of the transverse ligament. The common types of rheumatoid cervical spine are anterior atlantoaxial subluxation, vertical subluxation and subaxial subluxation. We describe a 61-year-old woman with only neck pain initially. An MRI of the cervical spine showed atlantoaxial subluxation with features of the rheumatoid involvement. Arthritis later developed in both hands and symmetrically in other peripheral joints. She was diagnosed as having RA. This is the first case report of RA presenting initially as atlantoaxial subluxation.