Rhino-Orbito-Cerebral Mucormycosis in an Immunocompromised Patient

Rhino-orbito-cerebral mucormycosis (ROCM) is an invasive fungal infection that usually occurs in immunocompromised patients. It is aggressive and has a high risk of mortality. With unclear guidelines, ROCM is treated in various ways. We present a patient who underwent kidney transplant and who treated for ROCM without major complications.

Treatment Results of Vocal Process Granuloma: Intubation Versus Contact Granuloma

Background and Objectives@#Vocal process granulomas (VPGs) are benign lesions of the larynx, typically contact granulomas (CG) and intubation granulomas (IG). The two diseases are known to have different clinical manifestations despite having the same pathological features. The purpose of this study was to analyze the treatment results for CG and IG and to obtain clinical information.Materials and Method We retrospectively reviewed the medical records of patients diagnosed with VPG between January 2015 and December 2018. The patient’s age, sex, medical history, lesion size, lesion type, reflux finding score, response to treatment, duration of treatment, and follow-up period were compared. @*Results@#In total, 32 patients were included in the study, of which 18 were CG and 14 were IG. In the CG group, males were dominant (n=15, 83.3%), whereas in the IG group, females were dominant (n=11, 78.6%) (p=0.0009). The response to medical treatment using proton pump inhibitor and steroid inhaler was better in the IG group (11/14, 78.6%) than in the CG group (7/18, 38.9%) (p=0.036). Of the 14 patients who did not respond to medical treatment, 5 received botulium toxin injections, and all 5 had complete remission. The duration of medical treatment was significantly longer in the IG group (p=0.0029). @*Conclusion@#IG was more common in female, and CG was more dominant in male. IG had better response to medical treatment using proton pump inhibitor and steroid inhaler than CG.

Nrf2-Heme oxygenase-1 modulates autophagy and inhibits apoptosis triggered by elevated glucose levels in renal tubule cells

BACKGROUND: Autophagy is a highly balanced process in which lysosomes remove aged and damaged organelles and cellular proteins. Autophagy is essential to maintain homeostasis in the kidneys. METHODS: Using human renal tubule cells HK-2, we assessed the impact of high glucose (HG) on autophagy. We also evaluated the capability of sulforaphane (SFN) to protect the HK-2 cells from HG-induced apoptosis by modulating autophagy. RESULTS: SFN modulated autophagy and decreased apoptosis in the HK-2 cells that were cultured in 250 mM glucose medium for two days. The reactive oxygen species (ROS) levels increased, as expected, in the cells cultured in the 250 mM glucose medium. However, the SFN decreased the ROS levels in the HK-2 cells. The overexpression of heme oxygenase-1 (HO-1) by SFN decreased the expression of LC3 and beclin-1. LC3 and beclin-1 were involved in the downregulation of caspase-3 that was observed in the HG-induced cells. CONCLUSION: The activation of nuclear factor E2-related factor 2 (Nrf2)–HO–1 inhibited ROS expression and subsequently attenuated autophagy and cell apoptosis after HG injury was decreased. HG injury led to the activation of autophagy and HO-1 in order to combat oxidative stress and protect against cell apoptosis. Therefore, HO-1 activation can prevent ROS development and oxidative stress during HG injury, which considerably decreases autophagy and apoptosis.

Malignant Hypertension with Pulmonary Alveolar Hemorrhage Needing Dialysis / 이화의대지

A 35-year-old man presented with progressive dyspnea and hemoptysis. His blood pressure was 230/140 mmHg and serum creatinine level was 20.13 mg/dL. Chest radiography and computed tomography revealed pulmonary hemorrhage. His renal function was low, thus emergent renal replacement therapy was required. Malignant hypertension and acute kidney injury were diagnosed, and antihypertensive therapy and hemodialysis started immediately. Renal biopsy was performed to examine the underlying disease. Typical pathological changes of malignant hypertension, fibrinoid necrosis of the afferent arterioles, and proliferative endoarteritis at the interlobular arteries were observed. His renal function improved gradually and pulmonary hemorrhage completely disappeared with administration of antihypertensive agents. Here, we report this rare case of malignant hypertension with pulmonary alveolar hemorrhage and speculate that the hemorrhage may be related to vascular injuries at the alveolar capillary level caused by malignant hypertension.

A Case of Acute Pancreatitis: Portal Vein Superimposed Thrombosis in a Nephritic Syndrome Patient / 대한내과학회지

Nephrotic syndrome is characterized by hypercoagulability and thrombosis of the renal and deep veins. We describe a case of unusual thrombosis in the portal and superior mesenteric veins of a 41-year-old female, admitted for treatment of abdominal pain, who simultaneously presented with nephrotic syndrome and acute pancreatitis. Laboratory analysis revealed hypoalbuminemia, hyperlipidemia, and proteinuria. Abdominal computed tomography revealed acute pancreatitis, thrombosis at the portal and superior mesenteric veins, and ischemic changes in the colon and small intestines. Anticoagulation therapy was started immediately. Abdominal pain was subsequently reduced and the ischemic lesion disappeared. Warfarin use could not be terminated immediately. Empirical steroid therapy commenced without a kidney biopsy. Complete remission occurred after 4 weeks. Following warfarin cessation, a kidney biopsy was performed, confirming the diagnosis of minimal change disease.

Fibrillary glomerulonephritis combined with chronic inflammatory demyelinating polyneuropathy

A 58-yr-old man presented with leg edema and subacute weakness of his bilateral lower extremities. Urinary and serum immunoelectrophoresis revealed the presence of lambda-type Bence Jones proteins. He was ultimately diagnosed with monoclonal gammopathy of undetermined significance (MGUS). A renal biopsy specimen showed fibrillary glomerulonephritis (FGN), which was randomly arranged as 12-20 m nonbranching fibrils in the basement membranes. Immunofluorescence studies were negative for immunoglobulin (Ig)G, IgM, IgA, C3, and kappa light chains in the capillary walls and mesangial areas. A Congo red stain for amyloid was negative. Electromyography and nerve conduction velocity examinations results were compatible with the presence of demyelinating polyneuropathy. This case showed a rare combination of FGN, without Ig deposition, and MGUS combined with chronic inflammatory demyelinating polyneuropathy (CIDP).

A Case of Different Organ Responses to Immunosuppressive Therapy In a Microscopic Polyangiitis Patient with Interstitial Lung Disease / 대한내과학회지

Microscopic polyangiitis (MPA) is an idiopathic autoimmune disease characterized by systemic vasculitis associated with antineutrophil cytoplasmic autoantibodies. Interstitial lung disease is a less recognized manifestation of MPA and has a poor prognosis. A 61-year-old man presented with persistent cough, sputum and dyspnea. Laboratory examination revealed microscopic hematuria and renal insufficiency. Perinuclear anti-neutrophil cytoplasmic autoantibodies were positive according to serological testing. Computed tomography scans showed bibasilar reticulation and honeycombing in a peripheral distribution. Therefore, renal biopsy was performed, and MPA was diagnosed. After treating with corticosteroids and immunosuppressive agents, the patient had a complete renal response but progressive interstitial lung disease. We report a case of MPA presenting with interstitial lung disease in which the patient experienced different responses in each organ.

A Case of Idiopathic Aortitis with Left Renal Vein Thrombosis

A 38-year-old man was admitted to the hospital because of abrupt left flank pain. He had no fever and physical examination revealed tenderness of the left costovertebral angle. Laboratory data revealed white blood cell 16,060/microL, C-reactive protein 0.93 mg/dL. Urinalysis showed more than 1/2 red cells per high-power field with severe proteinuria (4+). Enhanced computed tomography (CT) showed the thickened abdominal aorta wall with partial thrombus. The thickened aorta wall compressed the left renal vein and it caused left renal vein thrombosis. Abdominal CT findings suggested aortitis of the abdominal aorta with complication of left renal vein. We could exclude other types of aortitis including autoimmune aortitis, Takayasu's arteritis, giant cell arteritis, and infectious causes based on a serologic test and the history of the patient. Therefore, the patient was diagnosed with idiopathic aortitis and treated with glucocorticoid. After treatment, his symptoms disappeared and a follow-up CT showed decreased mural thickening of the abdominal aorta. Isolated idiopathic aortitis presented with renal vein thrombosis is extremely rare and has not been reported in Korea yet. We present a rare case report on idiopathic aortitis of the abdominal aorta with complication of left renal vein thrombosis.

A Case of Systemic Lupus Erythematosus Occurring after H1N1 Influenza Vaccination / 대한내과학회지

The recent worldwide outbreak of H1N1 has led to the universal administration of H1N1 influenza vaccination, including in South Korea. Several complications have been reported with use of H1N1 influenza vaccine, but systemic lupus erythematosus (SLE) has not been reported as a complication until now. Here, we report a case of SLE occurrence after H1N1 influenza vaccination. A 17-year-old girl who had not been diagnosed with SLE was hospitalized with fever, myalgia, and arthralgia after H1N1 influenza vaccination. Laboratory tests revealed increased levels of antinuclear antibody and anti-ds-DNA antibody, and decreased levels of C3 and C4 as well as proteinuria. The pathological findings confirmed a diagnosis of lupus nephritis. The patient was treated with high-dose corticosteroid and hydroxychloroquine. This is the first report of SLE following H1N1 influenza vaccination in South Korea.

Porcelain Heart: Rapid Progression of Cardiac Calcification in a Patient with Hemodialysis

Cardiac calcification usually occurs in patients with end-stage renal disease. However, rapid progression of cardiac calcification is rarely associated with secondary hyperparathyroidism of end-stage renal disease. We report a patient with end-stage renal disease who showed moderate left ventricular hypertrophy at the first echocardiography, and showed severe myocardial calcification and severe mitral valve stenosis 4 years later. We suspected a rapid progression 'porcelain heart' cardiomyopathy secondary to hyperparathyroidism of end-stage renal disease. The patient underwent parathyroidectomy, and considered mitral valve replacement.

A Case of Non-Surgical Treatment in Hemodialysis Patient with Spontaneous Splenic Rupture / 대한신장학회지

Spontaneous splenic rupture is a rare disease but can cause a life threatening situation. It can occur under a pathological spleen such as infection, neoplastic, infiltrative and inflammatory disease. Although splenectomy is the treatment of choice for splenic rupture, it is uncertain that the effectiveness of non- surgical treatment in the hemodynamically stable patient. We report a case of a 66-year-old male undergoing hemodialysis for 4 years who presented to the emergency department with abdominal pain and distention. Blood pressure was 130/80 mmHg, heart rate was 108 bpm. White blood cell count was 7,130/mm3, hemoglobin was 6.7 g/dL, platelet was 156,000/mm3. PT INR was elevated up to 2.01 because he had taken warfarin due to splenic infarction. Abdominal CT scan revealed hemoperitoneum due to splenic rupture. We performed angiography but there was no active bleeding. We decided conservative management without embolization because of stable condition and increased bleeding risk in operation. He received 6 pints of packed red blood cell transfusion during continuous renal replacement therapy for 24 hours on ICU. He was discharged with complete recovery on the 21st hospital day. We suggest that non-surgical treatment in splenic rupture also could be considered in hemodynamically stable patients with a high risk of postoperative complication.

Immunoglobulin G4 Related Retroperitoneal Fibrosis with Acute Kidney Injury: Report of A Case / 대한신장학회지

Immunoglobuin G4 (IgG4)-related sclerosing disease is a recently recognized syndrome characterized clinically by male predominance, elevated serum IgG4 level, and good response to steroid therapy. The pathologic characteristics are extensive lymphoplasmacytic infiltration with IgG4-positive cell and irregular fibrosis in various organs (pancreas, bile duct, salivary gland, retroperitoneum, kidney and lung). Some inflammatory pseudotumors may be involved in this disease. Herein, we experienced a case of IgG4-related retroperitoneal fibrosis with postrenal acute kidney injury and inflammatory pseudotumor of thyroid in a 31-year-old female who underwent insertion of double J catheter at both ureters and received corticosteroid treatment.

Morphologic Changes in Nasal Mucosa of the Rat after Ozone Exposure / 대한이비인후과학회지

BACKGROUND AND OBJECTIVES: Ozone is the principal oxidant pollutant in photochemical smog. Although ozone-induced pulmonary changes have been morphologically characterized, effects of ozone on the upper respiratory tract have not been thoroughly investigated. The purpose of this study was to investigate the morphological change of nasal mucosa after acute exposure to ozone. MATERIAL AND METHODS: Rats are exposed to 0.3, 0.6, 0.9, and 1.2 ppm of 0, for 6 hours a day for 7 days. Rats were sacrificed 18h after the end of their last exposure. Nasal mucosa was processed for Hematoxylin/Eosin (H/E) stain and Alcian blue (pH 2.5)/Periodic Acid Schiff (AB/PAS) stain. RESULTS: Morphological changes such as infiltration of neutrophils, loss of cilia, epithelial hyperplasia, squamous metaplasia and secretory cell metaplasia were observed and these changes were more pronounced in the group exposed to high concentration of ozone, compared with the group exposed to low concentration. CONCLUSION: The results of this study may suggest that ozone exposure induces infiammatory, proliferative, and metaplastic responses in the nasal mucosa.

Morphologic Change of Nasal Epithelium in Animal Model with Nasal Hyperreactivity / 대한이비인후과학회지

BACKGROUND: Nasal hyperreactivity is a cardinal pathophysiological feature in allergic or nonallergic rhinitis. However, the mechanisms underlying nasal hyperreactivity are largely unknown. One of the proposed mechanisms is that epithelial damage may contribute to the development of nasal hyperreactivity. However, it is hard to find studies on this topic. OBJECTIVE: The aim of this study is to demonstrate whether the morphological change of nasal epithelium exists in animal model with nasal hyperreactivity or not. MATERIALS AND METHODS: Guinea pigs were sensitized in 10% TDI-ethyl acetate solution for 5 days, after which a recess of 3 weeks were allowed before exposing them in 5% TDI-ethyl acetate solution twice a week for 4 weeks. Thereafter, we observed the morphologic change of nasal mucosa with a light microscope and an electron microscope. RESULTS: Under the light microscopic observation, there were no morphological changes including epithelial damage in the TDI-provoked group. Under the electron microscopic, however, the widening of the intercellular space, the disruption of the basement membrane and the cytoplasmic vacuolization were observed. CONCLUSION: Morphological changes of the nasal epithelium were found in the animal model with nasal hyperreactivity under electron microscopic observation. Further studies to verify the relationship between the morphological changes and the nasal hyperreactivity will be needed.

A Clinical Study of Distant Metastases in Head and Neck Cancer / 대한이비인후과학회지

BACKGROUND AND OBJECTIVES: There are many failed cases with distant metastases (DMs) of head and neck cancer. In such cases, patients usually have poor prognosis, with a median duration of survival between 4 and 6 months. To find out the correlation between the general clinical aspects and distant metastases in patients with head and neck cancer, we analyzed our previous experiences. MATERIALS AND METHOD: We reviewed records retrospectively in 41 of 460 patients with head and neck cancers from 1986 to 1995. DMs were confirmed with X-ray, CT, MRI, liver scan, FNAC, PCNA, and biopsy. We used the staging system of American Joint Committee on Cancer. RESULTS: 1) Clinically manifested DMs were found in 8.9% (41/460) of patients. 2) DMs were frequently observed in the oropharynx (13.8%), oral cavity (11.4%), and larynx (10.3%) cancer. 3) The lung is the most common site of DMs for head and neck cancer. Liver and bone are the only other sites of DMs that are commonly clinically diagnosed. 4) DMs usually occur within 2 years of the initial diagnosis. 5) The incidence of DMs was significantly higher in the advanced T, N stages and clinical stage than in the early T, N stages and clinical stage (p<0.05). CONCLUSION: The results of this study suggest that the advanced T, N stages and clinical stage may be some of the most critical factors influencing the eventual development of DMs.