A Case of High Methotrexate-induced Acute Renal Failure Successfully Treated with Plasma Exchange and Hemodialysis / 대한혈액학회지

We describe the case of a 70-year old female who had developed acute renal failure following high dose methotrexate therapy for malignant lymphoma. Previously, she showed normal renal function and tolerance to high dose methotrexate therapy. Serum methotrexate level reached 9.25 micro mol/L and sustained elevated level for 1 week, although folic acid rescue was intensified to 150 mg intravenously every 3 hours. Therefore, 3 times total plasma exchange and one hemodialysis were performed, and serum methotrexate level returned to normal range. Acute renal failure induced by methotrexate can be complicated by prolonged high serum level of methotrexate, resulting in bone marrow suppression and severe mucositis. To lower the serum methotrexate level, dialysis, plasma exchange, hemoperfusion with charcoal only or combined with hemodialysis and carboxypeptidase-G2 were tried. Successful rescue was obtained by plasma exchange and hemodialysis. No rebound phenomenon was developed.

Fatal Pneumomediastinum and Subcutaneous Emphysema in a Patient with Dermatomyositis / 대한류마티스학회지

Dermatomyositis is a clinical entity characterized by a distinctive cutaneous rash and inflammatory myopathy. In this disorder, the pneumomediastinum is quite a rare complication and is assumed to result from air leakage due to vasculitis, lung fibrosis or rarely after bronchoscopic lung biopsy and pulmonary function test. We describe patient with dermatomyositis who developed pneumomediastinum, pneumothorax and massive subcutaneous emphysema after pulmonary function test. She died due to respiratory failure. We think that careful observation is required in performing PFT in dermatomyositis patients with presumed interstitial lung diseases.

A Case of Variant Angina Associated with Hyperthyroidism

While angina pectoris is not uncommonly seen in hyperthyroidism, only rare case reports have proved that the myocardial ischemia was induced by coronary artery spasm. A 62 year-old man with a prior diagnosis of hyperthyroidism presented with repeated episodes of syncope and chest pain. The coronary angiogram showed normal coronary arteries. Severe diffuse spasm of both coronary was spontaneously induced and normalized after intracoronary nitroglycerin injection during the procedure of coronary angiography. For one year, he was on simultaneous antianginal and antithyroidal medicines with accomplishment of euthyroid state. He did not experience and anginal symptom for the last six months. The followup coronary angiogram performed 1 year later revealed a newly developed atherosclerotic lesion (about 50% stenosis in diameter) at the proximal left anterior descending artery. However provocative challenge test with intracoronary acetylcholine infusion failed to induce coronary spasm at the lesion. We report a case of coronary artery spasm associated with hyperthyroidism with a review of literatures.

Changes of Glucose Tolerance in Acromegaly Patients with 24 Hour Continuous Subcutaneous Infusion of Octreotide / 대한내분비학회지

BACKGROUND: An important metabolic feature of acromegaly is a reduced action of insulin on hepatic gluconeogenesis and peripheral glucose disposal which mediated by growth hormone hypersecretion. Octreotide, a synthetic octapeptide somatostatin analogue exerts complex effects on hormonal and metabolic regulations affecting glucose homeostasis. This study was designed to ascertain the shorterm effect of octreotide on glucose tolerance in acromegaly. METHODS: 10 patients (five men and five women, age 47.9+/-11.8) were injected subcutaneously with octreotide, 100 micrograms for 24 hours. Patients were assessed with respect to growth hormone, glucose, and insulin response to a standard 100 g oral glucose tolerance test (OGTT) before and during the last 2 hour of octreotide infusion. RESULTS: During the therapy, there was significant decrease in mean blood glucose response to OGTT (678.4+/-51.9 vs 581.9+/-47.3 mg/dL/2hr: mean areas under the glucose curve, p=0.01) and mean serum insulin response to oral glucose load was significantly reduced in all patients (339.2+/-106.2 vs 256.7+/-111.3 U/mL/2hr: mean areas under the insulin curve, p=0.01). Using glucose tolerance test criteria three patients of 10 had normal glucose tolerance, four and three had impaired glucose tolerance and diabetes, respectively, at base line. While on octreotide these composition was changed to six patients of NGT, three of IGT and one diabetes. CONCLUSION: We conclude that insulin resistance mediated by GH hypersecretion was improved by shorterm octreotide treatment.

A Case of Type I Renal Tubular Acidosis Associated with Graves' Disease and Sjogren' s Syndrome / 대한신장학회잡지

Classic distal renal tubular acidosis(type 1 RTA) is a hypokalemic, hyperchloremic metabolic acidosis due to selective defect in distal acidification. Type 1 RTA may be associated with genetic(usually autosomal dominant) or autoimmune disease, drugs and toxin and various tubulointerstitial diseases. This case report describes a 27 year-old female patient with distal RTA, Sjogren' s syndrome and Graves' disease the first case. She had been suffered from muscle weakness and peripheral numbness and was found to have low serum potassium(1.6mEq/L). She was revealed to have 1) distal RTA by NaHCO3 loading test 2) Sjogren' s syndrome by Schirmer' s test and palate biopsy and 3) Graves' disease by exophthalmometry and autoantibody test, thyroid function test. This is the first case as far as I search that report the association of distal RTA, Sjogren' s syndrome, and Graves' disease caused by autoimmune mechanism.