COVID-19 Outbreak and Presymptomatic Transmission in Pilgrim Travelers Who Returned to Korea from Israel

Background@#On February 21, 2020, 2 coronavirus disease 2019 (COVID-19) cases in pilgrim travelers from Korea to Israel were identified. We investigated the source of infection, clinical features of COVID-19, and transmission potential of presymptomatic and asymptomatic cases. @*Methods@#All 39 pilgrim travelers were aggressively tested for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). Their clinical features and possible source of infection were investigated by interview and review of their medical records. Ten confirmed cases without symptoms at the first sampling dates were selected for follow-up reverse transcription polymerase chain reaction tests. @*Results@#Of the 39 pilgrim travelers, 30 (77%) were positive for SARS-CoV-2. Among the 30 positive COVID-19 cases, 4 (13%) were asymptomatic. Available follow-up cycle threshold values from 10 cases gradually increased over time and were lower during the presymptomatic period than during the postsymptomatic period. Out of 328 contacts related to the COVID-19 cases in the pilgrim travelers, 22 additional cases (7%) were confirmed with SARS-CoV-2 infections. Three tertiary cases were identified to be transmitted by presymptomatic secondary cases. @*Conclusion@#To prevent transmission of COVID-19, we need to focus on presymptomatic and asymptomatic cases, and massive testing for SARS-CoV-2 is required. More research about the possibility of presymptomatic transmission over 2 days before symptom onset is required.

COVID-19 in Nursing Facilities: Experience in Republic of Korea

ObjectivesCoronavirus disease 2019 (COVID-19) outbreaks in nursing facilities can easily lead to a high rate of infection and fatality. A surge in newly infected cases in the first quarter of 2020 in Gyeongsan-si, in the Republic of Korea, was followed by several outbreaks in nursing facilities in the same area. The aim of this study is to report on the epidemiological investigation and the management to reduce the infection rate in nursing facilities for older adults.MethodsThe municipal government and the Korea Centers for Disease Control and Prevention performed an epidemiological investigation into 5 nursing facilities that reported a high number of COVID-19 infection cases from February to May 2020. COVID-19 infected cases in the facilities were investigated to identify the infection routes, and the fatality rate of the 5 facilities.ResultsThe 5 facilities had a combined fatality rate of 12.2% (9 deceased among the 74 infected cases). The median age of the deceased was 87 years old (range: 82–91). The infection was first identified on February 27th, 2020, peaked on March 6th, and was last detected on March 24th, 2020.ConclusionDifficulties specific to such facilities included the delay in the recognition of symptoms and limitation in distancing. Tailored strategies such as daily monitoring of symptoms and proactive COVID-19 screening of quarantined residents, contributed to a decline in the infections in the facilities.

COVID-19 Outbreak and Presymptomatic Transmission in Pilgrim Travelers Who Returned to Korea from Israel

Background@#On February 21, 2020, 2 coronavirus disease 2019 (COVID-19) cases in pilgrim travelers from Korea to Israel were identified. We investigated the source of infection, clinical features of COVID-19, and transmission potential of presymptomatic and asymptomatic cases. @*Methods@#All 39 pilgrim travelers were aggressively tested for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). Their clinical features and possible source of infection were investigated by interview and review of their medical records. Ten confirmed cases without symptoms at the first sampling dates were selected for follow-up reverse transcription polymerase chain reaction tests. @*Results@#Of the 39 pilgrim travelers, 30 (77%) were positive for SARS-CoV-2. Among the 30 positive COVID-19 cases, 4 (13%) were asymptomatic. Available follow-up cycle threshold values from 10 cases gradually increased over time and were lower during the presymptomatic period than during the postsymptomatic period. Out of 328 contacts related to the COVID-19 cases in the pilgrim travelers, 22 additional cases (7%) were confirmed with SARS-CoV-2 infections. Three tertiary cases were identified to be transmitted by presymptomatic secondary cases. @*Conclusion@#To prevent transmission of COVID-19, we need to focus on presymptomatic and asymptomatic cases, and massive testing for SARS-CoV-2 is required. More research about the possibility of presymptomatic transmission over 2 days before symptom onset is required.

A Case of a Child with Seizure caused by Organophosphate Poisoning / 대한소아신경학회지

Seizure is a temporary symptom or sign which is caused by an abnormal electrical stimulation of brain. Depending on whether a seizure has preceding factors or not, it can be further categorized into provoked and unprovoked seizure. In provoked seizure, it is important to find a cause for treatment. In this study, we would like to report a case of a 6 year-old male child with seizure caused by organophosphate poisoning. The patient's chief complaint was his decreased mental status accompanying seizure. Initially, status epilepticus was suspected but the response to anticonvulsants was not good, and resulted in prolonged respiratory failure. After 3 hours, the patient showed signs of cholinergic crisis. In response, atropine was administered and the condition improved. If respiratory failure or mental confusion persists even after cessation of seizure in status epilepticus, repetitive physical and neurological examinations should be carried out to find preceding factors. Even though the recent incidence of organophosphate poisoning has decreased, we would like to emphasize from our study that it should be considered as a preceding factor for seizure.

Cancer in thyroid nodules with fine-needle aspiration in Korean pediatric populations

PURPOSE: To determine the prevalence and clinical findings of benign thyroid nodules and cancer in Korean pediatric patients with thyroid nodules. METHODS: We investigated the medical records of 134 patients aged younger than 18 years who had a goiter, thyroid nodule, thyroid mass, or thyroid cancer who underwent fine needle aspiration biopsy (FNAB). RESULTS: The study population included 113 females (84.3%) and 21 males (13.7%); the mean patient age was 16.1±2.3 years (range, 8–18 years). Of the 134 patients, 24 (18.0%) were finally diagnosed with thyroid cancer, of which 20 (83.3%) were papillary cancer and 4 (16.7%) were follicular cancer. No patient was exposed to radiation. FNAB revealed malignant cancer in 21 of the patients; 3 were initially reported as having benign tumors by FNAB, but were later diagnosed with follicular cancer. An additional 13 patients were suspected to have malignant tumors by FNAB, with a final diagnosis of nodular hyperplasia. Cystic nodules were more common in the benign group. The percentages of cervical lymphadenopathy and irregular nodular margins were higher in the malignant group compared to the benign group. Cervical lymphadenopathy and FNAB malignant findings were highly suggestive of malignant nodules. CONCLUSIONS: Thyroid cancer prevalence in a Korean pediatric population is comparable to reported estimates of worldwide thyroid cancer prevalence. In this population, cancer predominates on the right thyroid lobe. Papillary thyroid cancers are dominant in the Korean pediatric population but are less prevalent than in Korean adults. As expected, FNAB was highly accurate in predicting malignant nodules.

A Feasibility Study for Cryopreserving Peripheral Blood Stem Cell Collects at High Cell Concentration / 대한수혈학회지

BACKGROUND: For autologous hematopoietic stem cell transplantation (HSCT), the volume of infused and DMSO contained in graft are the major causes of complications related to infusion. In this study, we evaluated feasibility of cryopreserving peripheral blood stem cell collects (PBSCC) at high cell concentration. METHODS: PBSCC from 40 patients with multiple myeloma or lymphoma were split and cryopreserved at two different concentrations of TNCs; one for standard concentration (SC) (2x108 cells/mL) and the other for high concentration (HC) (3x108 cells/mL). The viability of total nucleated cells and CD34+ cell count were examined before cryopreservation and after thawing. CFU-GM was examined with thawed products. Data were analyzed as two groups between good mobilizer (GM) and poor mobilizer (PM). RESULTS: There were no differences in TNC viability between SC and HC of all patients (P=0.0656) and PM (P=0.9658), however HC of GM showed significantly lower viability than SC (P=0.0314). CD34+ cell viability did not differ between SC and HC. CD34+ cell recovery was decreased in HC of all patients (P=0.459) and GM (P=0.0164), but no differences between SC and HC in PM (P=0.9658). CFU-GM clonogenic efficiency between SC and HC was not different in all patients (P=0.0635) and PM (P=0.8984), but was decreased in HC of GM (P=0.0427). CONCLUSION: Cryopreservation of PBSCC at 3x108 cells/mL seems to have minimal adverse effect on the quality of PBSC after thawing, particularly in PM. This approach may help to reduce infusion related complications while decreasing the cost of processing and storage of PBSCC.

Occupational disease surveillance system in Busan, Ulsan, Kyung-Nam area / 대한산업의학회지

OBJECTIVE: Occupational medicine specialists in the Busan, Ulsan and Kyung-Nam areas established an area-based occupational disease surveillance system and used this system to collected case information for the purpose of preventing occupational diseases METHODS: 11 hospitals participated in this system. The authors selected five main diseases, which were hand-arm vibration syndrome (HAVS), work-related musculoskeletal disorder (WRMSD), occupational asthma, occupational skin disease and occupational lung cancer and established their case definitions. All cases were reported on the web, and real time analysis was conducted. RESULTS: Between Apri1 2001 and April 2003, 192 cases of HAVS, 118 cases of WRMSD, 33 cases of occupational asthma, 17 cases of occupational skin disease and 17 cases of occupational lung cancer (for a total of 377 cases of these five main diseases) were reported. Most of the HAVS cases came from shipbuilding, and 172 of them (92.7 %) were associated with grinding. Of the four main types of WRMSD, carpal tunnel syndrome (CTS) was the most prevalent with 46 cases and shipbuilding was also the main industry involved (83.9 %). The ergonomic risk factors involved mainly associated with the hand. In 19 (57.6 %) and 4 (12.1 %) cases of occupational asthma, the agents included isocyanate and welding fume, respectively. 64.7 % of the cases of occupational skin diseases were contact dermatitis, and organic solvents and welding fume were the main agents involved. The causative agents of occupational lung cancer included Cr, welding fume, PAH, Ni, etc. 10 (58.8 %) of the cases were diagnosed as squamous cell carcinoma and 5 (29.4 %) as adenoma. CONCLUSION: This result showed that an area-based occupational disease surveillance system might provide an effective method of evaluating the prevalence of such diseases, however the Busan, Ulsan and Kyung-Nam provinces are too large to be treated as individual areas. Therefore, the authors suggest that each province should establish its own surveillance system.

Two Cases of Crohn's Disease with Myelodysplastic Syndrome / 대한혈액학회지

Myelodysplastic syndromes (MDS) are bone marrow stem cell disorders characterized by dysplastic hematopoiesis leading to peripheral pancytopenias, and by a high risk of progression to acute myeloid leukemia. Several immunological disorders, particularly relapsing polychondritis, seronegative arthritis and cutaneous vasculitis have been described in association with MDS. Crohn's disease is an inflammatory bowel disease characterized by inflammatory, ulcerative bowel lesions and frequent association with systemic manifestations. Recently, some researchers have suggested that an association may exist between MDS and inflammatory bowel diseases, especially Crohn's disease, based on concomittant findings of both disorders in some reported patients. We report here two cases who developed MDS and Crohn's disease concurrently, and review previously reported literatures.

A Case of Refractory Iron Deficiency Anemia / 대한혈액학회지

Iron deficiency is the most common cause of anemia worldwide. The goal of therapy for iron deficiency anemia (IDA) is to supply sufficient iron to repair the hemoglobin deficit and replenish storage iron, combined with correction of underlying conditions. The majority of patients with IDA respond well to oral or parenteral iron replacement therapy if appropriately prescribed, but some rare cases of IDA refractory to both oral and parenteral iron replacement therapy due to in-born error of iron metabolism have been reported previously. We report here a mysterious case of IDA refractory to both oral and parenteral iron therapy and even to red cell transfusions. A 21-year-old male patient was admitted to our hospital due to general weakness and dizziness. His hemogram, iron profiles and bone marrow study showed the findings compatible with IDA. We could not find any conditions that cause acute or chronic blood loss, or any evidence of in-born error of iron metabolism. In spite of adequate iron relplacement therapy via both oral and parenteral routes, and even with red cell transfusions, his hemogram and iron profiles were not improved.

Transplantation of peripheral blood stem cells mobilized by intensified consolidation and granulocyte colony-stimulating factor in acute leukemia

The purpose of this study was to evaluate the feasibility and efficacy of autologous transplantation of peripheral blood stem cells (PBSC) mobilized with high-dose consolidation chemotherapy and granulocyte colony-stimulating factor in patients with acute myelogenous leukemia (AML). Twenty patients received myeloablative chemotherapy or chemo-radiotherapy including total body irradiation followed by the infusion of PBSC. PBSC were collected by large-volume leukaphereses. The mean number of mononuclear cells and CD34-positive cells infused were 7.2 x 10(8)/kg (range, 2.2-16.6), and 6.6 x 106/kg (range, 2.1-27.7), respectively. Engraftment failure was not seen in the enrolled patients. The median time to neutrophil (> or = 500/microL) and platelet recovery (> or = 50,000/microL) from the transplant was 12 days (range, 8-20) and 28 days (range, 10-600), respectively. The 2-year probability of disease-free survival (DFS) and relapse were 43% and 57% for patients with AML transplanted in first complete remission (CR1). The outcome of the patients transplanted in the advanced status was significantly worse than the patients transplanted in CR1 (P=0.04). Most relapses occurred within 1 year after transplantation. Fatal hepatic veno-occlusive disease was observed in one case. Other transplantation-related toxicities were mild. Our results demonstrated that autologous transplantation of high-dose consolidation chemotherapy-mobilized peripheral blood progenitor cells is feasible in the patients with AML in CR1. To further reduce the risk of leukemia relapse, much effort should be contributed to the field of ex vivo purging and post-transplant immunotherapy.

Treatment outcome and survival rate of primary cutaneous lymphomas / 대한내과학회지

BACKGROUND: Primary cutaneous lymphomas are very rare type of malignant lymphomas. They represent a heterogeneous group of T-cell and B-cell lymphomas with considerable variations in clinical presentation, histopathology, immunophenotype, and prognosis. In this report, we evaluated the clinical characteristics of primary cutaneous lymphoma according to their clinical stages and histopathologic types. METHODS: From January, 1985 to Jun, 1999, 23 patients with histopathologic diagnosis of primary cutaneous lymphoma were evaluated retrospectively. RESULTS: The mean age was 48.5 years at the time of diagnosis of primary cutaneous lymphomas, and the most frequent form of cutaneous involvement was nodule(35%). The average duration from the occurrence of cutaneous lesion to the diagnosis of primary cutaneous lymphoma was 29.8 months. There were 20 cases(87%) of primary cutaneous T cell lymphomas, whereas primary cutaneous B cell lymphomas were seen in 3 cases(13%). The patients with stage I were 9 cases(39%), whereas the patients with stage IV were 10 cases(43%). Complete remission rate was 29% and partial remission rate was 57%. Median disease-free survival duration was 7 months and median overall survival duration was 33 months. One-year overall survival rate was 63.3% and 3-year overall survival rate was 56.3%. CONCLUSION: Primary cutaneous lymphomas were usually diagnosed at a far-advanced stage, and showed poor treatment results. Therefore early diagnosis is important to improve the survival rate. There should be carefully follow-up and repeated tissue diagnosis of the skin lesions which had a suspicion of primary cutaneous lymphoma and had not responded to conservative treatment.

Acute tumor lysis syndrome in patients with non-Hodgkin's lymphoma / 대한내과학회지

BACKGROUND: Acute tumor lysis syndrome(TLS) has been defined as the metabolic abnormalities that occur after rapid tumor breakdown. In this study, we have evaluated the types or degrees of metabolic abnormalities and clinical characteristics in patients with non-Hodgkin's lymphoma(NHL) who developed TLS. METHODS: Patients were considered to have 'laboratory TLS(LTLS)' if any two of the following metabolic abnormalities occurred spontaneously or within 4 days of treatment: hyperphosphatemia, hyperkalemia, hyperuricemia, azotemia, and hypocalcemia. 'Clinical TLS(CTLS)' was defined as LTLS plus one of the following: a serum potassium level greater than 6.0mEq/L, a creatinine level greater than 2.5mg/dL, a calcium level less than 6.0mg/dL, the development of a life-threatening arrhythmia, or sudden death. RESULTS: Of 111 cases with NHL, TLS occurred in 16(14.4%), LTLS in 11(9.9%), and CTLS in 5(4.5%). There was a significant difference of gender, histologic type, clinical stage, performance status, extranodal involvement, serum lactate dehydrogenase(LDH), LDH index, beta2-microglobulin, uric acid, and blood urea nitrogen(BUN) level in the TLS versus control group. In multiple regression analysis, TLS occurred more frequently in patients with pre-treatment azotemia, aggressive histologic type, and elevated serum LDH level(p< 0.05, respectively). Pre-treatment and post-treatment TLS occurred in 8 cases(50%) respectively. The common metabolic abnormalities included hyperphosphatemia(87.5%), azotemia(81.3%), and hypocalcemia(75%). Of 11 cases with conservative care, 8 cases recovered within several days, but 3 cases died with multi-organ failure from disease progression. All 5 cases after hemodialysis for TLS recovered without any significant complications. CONCLUSION: The current study suggests that all patients with high-grade lymphomas and pre-treatment azotemia or a high serum LDH level be carefully monitored for at least 4 days after chemotherapy.

A Case of Colonic Perforation associated with CMV Colitis in a Patient with Non-Hodgkin's Lymphoma / 대한혈액학회지

Cytomegalovirus (CMV) disease in gastrointestinal tract is common among immunocompromised host. Ulcer, hemorrhage and perforation are manifestations of CMV infection in gastrointestinal tract and the most common site of intestinal perforation is the colon, followed by the distal ileum. Early diagnosis and preemptive therapy of CMV infection in the gastrointestinal tract should be warranted to prevent intestinal perforation, one of life-threatening complications of CMV colitis. We report a case of CMV colitis leading to colonic perforation in a patient with non-Hodgkin's lymphoma (T/NK cell lymphoma). Immunohistochemical stain of surgical specimen revealed positive, followed by positive EA-IPA and PCR for CMV antigen. He survived after successful left hemicolectomy and intravenous ganciclovir therapy.

A Case of Pleural Involvement in Patient with Waldenstr m's Macroglobulinemia / 대한혈액학회지

Waldenstr m's macroglobulinemia (WM) is a rare lymphoproliferative disorder characterized by lymphocytic tumor infiltration of the bone marrow and monoclonal IgM gammopathy. There had been anecdotal reports of pleural involvement in WM. We experienced a case of WM with pleural involvement and reported here for the first time in Korea with review of literature. A 73-year-old male patient was admitted to our hospital due to dizziness and general weakness. Serum protein electrophoresis showed M-peak in the gamma-globulin region, which was revealed as IgM kappa macroglobulin by serum and urine immunoelectrophoresis. He complained headache, visual disturbance and epistaxis associated with hyperviscosity syndrome and plasma filtration and combination chemotherapy was performed immediately. Symptoms and laboratory parameters such as serum IgM level and globulin fraction were markedly improved thereafter. But during the treatment, insidiously progressive exertional dyspnea was developed and the chest X-ray showed bilateral pleural effusion. The pleural fluid contained abundant plasmacytoid lymphocytes with reactive mesothelial cells. His dyspnea was completely resolved with clearing of the radiographic pleural effusion after continued steroid therapy.

A Case of Mucormycosis in a Patient with Myelodysplastic Syndrome and Review of the Literature in Korea / 감염

BACKGROUND: Mucormycosis is a highly virulent and rapidly progressive infectious disease caused by Mucorales. Immunocompromised hosts, such as patients with poorly controlled diabetes mellitus or diabetic ketoacidosis, patients receiving long-term deferoxamine therapy, and patients with hematologic malignancy, are predisposed to mucormycosis. We presented a case of brain abscess in a patient with myelodysplastic syndrome, and reviewed the cases of mucormycosis reported in Korea. METHODS: Relevant reports on mucormycosis were collected by searching the Korean database of medical literature. A total of 57 cases from 41 reports in Korea were reviewed as to clinical types, predisposing factors, treatments, and outcomes. RESULTS: The male to female ratio was 1.2:1. The mean age was 44 (range 1-72) years. The most frequent predisposing factor was diabetes mellitus (40 %), followed by the use of immunosuppressive agents (21%), and hematologic malignancies (16%). The most frequent clinical type was rhinocerebral (65%), followed by gastrointestinal (12%), pulmonary (9%), cutaneous (7%), and disseminated type (5%). The overall mortality rate was 33.3%, and the mortality rate in patients treated with surgical debridement was lower that in patients treated medically. The mortality rate in patients receiving surgical debridement only 13.3%, surgical debridement plus amphotericin B 26.9%, amphotericin B only 44.4%, and supportive care only 85.7%. Patients with disseminated type had a higher mortality rate than the other types. Conclusions:Early diagnosis of mucormycosis followed by the removal of predisposing factors and aggressive management, such as early surgical debridement and use of amphotericin B greatly affect therapeutic outcome. Therefore, much attention to the clinical features and identification of the organism are warranted. Collaborative evaluation through the collection of more cases with mucormycosis may be required in order to clarify the characteristics of mucormycosis in Korea.

A Case of Mucormycosis in a Patient with Myelodysplastic Syndrome and Review of the Literature in Korea / 감염

BACKGROUND: Mucormycosis is a highly virulent and rapidly progressive infectious disease caused by Mucorales. Immunocompromised hosts, such as patients with poorly controlled diabetes mellitus or diabetic ketoacidosis, patients receiving long-term deferoxamine therapy, and patients with hematologic malignancy, are predisposed to mucormycosis. We presented a case of brain abscess in a patient with myelodysplastic syndrome, and reviewed the cases of mucormycosis reported in Korea. METHODS: Relevant reports on mucormycosis were collected by searching the Korean database of medical literature. A total of 57 cases from 41 reports in Korea were reviewed as to clinical types, predisposing factors, treatments, and outcomes. RESULTS: The male to female ratio was 1.2:1. The mean age was 44 (range 1-72) years. The most frequent predisposing factor was diabetes mellitus (40 %), followed by the use of immunosuppressive agents (21%), and hematologic malignancies (16%). The most frequent clinical type was rhinocerebral (65%), followed by gastrointestinal (12%), pulmonary (9%), cutaneous (7%), and disseminated type (5%). The overall mortality rate was 33.3%, and the mortality rate in patients treated with surgical debridement was lower that in patients treated medically. The mortality rate in patients receiving surgical debridement only 13.3%, surgical debridement plus amphotericin B 26.9%, amphotericin B only 44.4%, and supportive care only 85.7%. Patients with disseminated type had a higher mortality rate than the other types. Conclusions:Early diagnosis of mucormycosis followed by the removal of predisposing factors and aggressive management, such as early surgical debridement and use of amphotericin B greatly affect therapeutic outcome. Therefore, much attention to the clinical features and identification of the organism are warranted. Collaborative evaluation through the collection of more cases with mucormycosis may be required in order to clarify the characteristics of mucormycosis in Korea.