A Case of Metformin-Induced Lactic Acidosis with Acute Kidney Injury Misdiagnosed as Hepatorenal Syndrome in a Cirrhosis Patient / 대한내과학회지

Metformin is a well-established drug for the treatment of type 2 diabetes mellitus. The incidence of metformin-induced lactic acidosis is low, but the estimated mortality rate is approximately 50% in cases with lactic acidosis in combination with metformin therapy. Lactic acidosis occurs most often in patients with compromised cardiac, pulmonary, hepatic, and/or renal function. Acute kidney injury is a relatively frequent problem in cirrhosis patients. Hepatorenal syndrome is a diagnosis of exclusion, making its diagnosis difficult in the clinical field. We report a case of metformin-induced lactic acidosis with acute kidney injury that was misdiagnosed as hepatorenal syndrome in a cirrhosis patient.

A Case of Metformin-Induced Lactic Acidosis with Acute Kidney Injury Misdiagnosed as Hepatorenal Syndrome in a Cirrhosis Patient / 대한내과학회지

Metformin is a well-established drug for the treatment of type 2 diabetes mellitus. The incidence of metformin-induced lactic acidosis is low, but the estimated mortality rate is approximately 50% in cases with lactic acidosis in combination with metformin therapy. Lactic acidosis occurs most often in patients with compromised cardiac, pulmonary, hepatic, and/or renal function. Acute kidney injury is a relatively frequent problem in cirrhosis patients. Hepatorenal syndrome is a diagnosis of exclusion, making its diagnosis difficult in the clinical field. We report a case of metformin-induced lactic acidosis with acute kidney injury that was misdiagnosed as hepatorenal syndrome in a cirrhosis patient.

Rhabdomyolysis of Calf Area Associated with Lithotomy Position for Laparoscopic Myomectomy / 대한내과학회지

Rhabdomyolysis is a syndrome characterized by muscle necrosis and release of intracellular muscle constituents into the circulation. It can occur in various diseases and conditions involving destruction of muscle membranes, including muscle strain, persistent coma, drug or alcohol abuse, connective tissue disease, excessive exercise, and surgery. Many factors have been implicated in the development of rhabdomyolysis during surgery; these include patient positioning with obstructed blood flow of either a femoral vessel at the hip or a popliteal vessel at the knee. Rhabdomyolysis can also be caused by muscle compression due to operative positioning during prolonged surgery. Surgery performed in the lithotomy position sometimes results in serious complications of rhabdomyolysis and acute renal failure. We report a case of rhabdomyolysis of both calves associated with the lithotomy position for laparoscopic myomectomy.

Newly Developed Multiple Myeloma in a Patient with Primary T-Cell Lymphoma of Bone

Primary non-Hodgkin's lymphoma of bone (PLB) is rare, and generally presents as a single extensive and destructive bone lesion. Histopathologically, most cases present as diffuse large B-cell lymphoma, and T-cell lymphoma is rare. By contrast, multiple myeloma is a disease defined as the neoplastic proliferation of a single clone of plasma cells producing a monoclonal immunoglobulin. We report a case of multiple myeloma that developed during treatment of PLB in a type of T-cell. A 48-yr-old man was diagnosed as T-cell PLB, stage IE, 18 months ago. The patient received the chemoradiotherapy and salvage chemotherapy for PLB. However, the lymphoma progressed with generalized bone pain, and laboratory findings showed bicytopenia and acute renal failure. On bone marrow biopsy, the patient was diagnosed as having multiple myeloma newly developed with primary T-cell lymphoma of bone. In spite of chemotherapy, the patient died of renal failure.

Enterococcus gallinarum native valve endocarditis in an immunocompetent patient / 대한내과학회지

Motile Enterococci, including Enterococcus gallinarum and Enterococcus casseliflavus/flavescens are rarely encountered in human clinical specimens. Enterococcus gallinarum is intrinsically resistant to low levels of vancomycin and causes bacteremia or infection among immunosuppressed or chronically ill patients, sometimes through nosocomial acquisition. We report a case of native valve endocarditis caused by Enterococcus gallinarum in an immunocompetent patient without any medical history.

The Efficacy of an Induction Chemotherapy Combination with Docetaxel, Cisplatin, and 5-FU Followed by Concurrent Chemoradiotherapy in Advanced Head and Neck Cancer / Journal of the Korean Cancer Association, 대한암학회지

PURPOSE: This study was performed to determine the feasibility and safety of the use of induction chemotherapy combined with docetaxel, cisplatin, and 5-fluorouracil (TPF) followed by concurrent chemoradiation therapy for locally advanced squamous cell carcinoma of the head and neck (SCCHN). MATERIALS AND METHODS: The patients, that were initially not treated for locally advanced SCCHN, underwent three cycles of induction chemotherapy every 3 weeks at a dose of 70 mg/m2 docetaxel D1, 75 mg/m2 cisplatin D1, 1000 mg/m2 5-FU D1-4, and subsequently received concurrent chemoradiation therapy. RESULTS: Forty-nine patients were enrolled in this study and forty-three of the patients completed the treatment. The median duration of follow-up was 18 months (range, 6~39 months). All of the patients had stage III (26.5%) or IV (73.5%) squamous cell carcinoma. After sequential therapy, a complete response and partial response was seen in 28 (65.2%) and 13 (30.2%) patients, respectively. The overall response rate was 95.4%. Overall survival and progression-free survival (PFS) at 2 years were 88.7% and 69.7%, respectively. Grade 3~4 neutropenia occurred in 42.2% of the patients and grade 4 thrombocytopenia in 1 cycle (0.7%). Two patients (4.1%) died during the induction chemotherapy due to pneumonia and a subdural hemorrhage, respectively. The group of patients over 65 years of age showed a significant lower dose intensity than that of patients under 65 years of age, but PFS was not significantly different between two groups (p=0.105). CONCLUSION: TPF induction chemotherapy followed by concurrent chemoradiotherapy showed a high level of CR and moderate treatment-induced toxicity. Adequate dose modification in elderly patients should be considered to maintain efficacy and avoid treatment-related toxicity.

Relationship between decreased renal function and hemoglobin / 대한내과학회지

BACKGROUND: The goal of this study is to define the relationship between the decreased renal function and anemia, and also to determine whether this relationship is different in male and female patients. METHODS: We conducted a retrospective study of 289 patients (male:female=157:132) who were followed at the department of internal medicine at Chonnam National University Hospital. General linear models were used to analyze the relationship between the hemoglobin concentration and Modification of Diet in the Renal Disease formula estimated Glomerular Filtration Rate (mL/min/1.73 m2). RESULTS: Among all patients, the mean hemoglobin concentration and hematocrit of the men with a Glomerular Filtration Rate of 50~59 mL/min/1.73 m2 was an absolute change of 0.8 g/dL (p=0.021) and it was 2.6% (p=0.011) lower than those of the patients with a Glomerular Filtration Rate> or =90 mL/min/1.73 m2 and continued to decrease further as the Glomerular Filtration Rate decreased, respectively (Hgb.: r=0.635, Hct.: r=0.640, all p or =90 mL/min/1.73 m2 and continued to decrease as the Glomerular Filtration Rate decreased, respectively (Hgb.: r=0.698, Hct: r=0.689, all p or =90 mL/min/1.73 m2 and continued to decrease further as the Glomerular Filtration Rate decreased, respectively (Hgb.: r=0.672, Hct.: r=0.687, all p<0.001). CONCLUSIONS: A decrease in the hemoglobin concentration was statistically significant in the patients of both genders, along with a moderately decreased Glomerular Filtration Rate (< or =60 mL/min/1.73 m2).

A Case of Ganglioneuroma in a Patient with Gross Hematuria / 대한신장학회잡지

Ganglioneuroma is a rare benign neoplasm that originates from the neural crest tissue and is characterized histologically by the composition of mature ganglion cells and Schwann's cells. Its definitive diagnosis is achieved by histological examination and most ganglioneuromas arise in the posterior mediastinum followed by the retroperitoneum. Due to the slow growth of the tumor, it may be incidentally detected in imaging studies for unrelated reasons and most of them are clinically silent. Recently a 18-year-old man visited Chonnam National University Hospital because of intermittent gross hematuria. We tentatively diagnosed him as renal cyst or retroperitoneal benign cystic tumor by abdominal CT and MRI, however biopsy result of surgically resected tumor showed that it contained Schwann's cells and mature ganglion cells, thus we confirmed the diagnosis of retroperitoneal ganglioneuroma. To our best knowledge, this is the first reported case of retroperitoneal ganglioneuroma with gross hematuria in Korea, so we report the case with reviews of other literatures.

Successful Treatment with Etanercept in a Patient with Adult-onset Still's Disease / 대한류마티스학회지

Adult-onset Still's disease (AOSD) is a rare systemic inflammatory disorder of unknown etiology. Non-steroidal anti-inflammatory drugs (NSAIDs), steroids, disease modifying anti-rheumatic drugs (DMARDs), immunosuppressives and intravenous immunoglobulin (IVIG) have been used to control the disease. It was suggested that several pro-inflammatory cytokines, such as interleukin (IL)-6, IL-8, IL-18, and tumor necrosis factor (TNF)-alpha, play an important role in its pathogenesis. Recent reports showed the clinical effectiveness of TNF-alpha blockers (infliximab and etanercept) in refractory AOSD. We report a case successfully treated with etanercept in the early AOSD refractory to the combination therapy of high-dose prednisolone and cyclosporine (CSA).

Diagnostic Noninvasive Tests for Coronary Artery Disease in Chronic Renal Failure Patients / 대한신장학회잡지

BACKGROUND: As ischemic heart disease is the major cause of death in chronic renal failure patients, screening tests are clinically important. Although coronary angiography is considered the gold standard for the diagnosis of coronary artery disease, other noninvasive tests are usually used to avoid this potentially dangerous and costly procedure. METHODS: We retrospectively determined the sensitivity, specificity, and positive and negative predictive values for electrocardiography, echocardiography, cardiac enzyme determination, and Technetium 99m tetrofosmin (TF) single photon emission computed tomography (SPECT) in 61 chronic renal failure patients who underwent coronary angiography. RESULTS: Nineteen patients (31.1%) were undergoing chronic hemodialysis, seven patients (11.4%) were undergoing peritoneal dialysis, and thirty five patients (57.3%) were undergoing conservative treatment. 99mTc SPECT had a sensitivity of 96% and specificity of 19%. Although echocardiography and tronponin-T had a relatively lower sensitivity of 69 % and 56% than 99mTc SPECT, they had a higher specificity of 63% and 63%, respectively. 99mTc SPECT had the highest sensitivity of 88% and echocardiography had the highest specificity of 78% in renal replacement group. 99mTc SPECT had the highest sensitivity of 100% and Troponin T had the highest specificity of 71% in conservative treatment group. CONCLUSION: Noninvasive test for coronary artery disease in patients with chronic renal failure, especially 99mTc SPECT is of limited value because of their low specificity, so echocardiography and troponin T may helpful for diagnosing coronary artery disease.