Two cases of acute renal failure secondary to acute pyelonephritis / 대한내과학회지

Acute renal failure secondary to acute pyelonephritis is developed rarely. But acute pyelonephritis is considered in differential diagnosis of acute renal failure, particularly in elderly patient. Elderly patient showed subtle symptoms or signs of infections and can be missed easily. We experienced two cases of acute renal failure secondary to acute pyelonephritis. In first case, one patient complained fever, chilling and right flank pain for 10 days. Three repeated blood and urine cultures showed E. coli, respectively. At admission serum creatinine showed 2.4 mg/dL and thereafter increased to 4.5 mg/dL, and then decreased to 1.7 mg/dL with antibiotic therapy and hydration at 14 days of admission. In second case, patient complained right flank pain, costovertebral tenderness and urinary difficulty at admission. Two repeated blood culture showed no growth, two repeated urine culture showed > 105 ml/dL of E. coli. At admission serum creatinine level was 2.69 mg/dL and then decreased to 1.7 mg/dL with antibiotic therapy and hydration at 14 days of admission.Acute pyelonephritis should be considered in differential diagnosis of acute renal failure in the elder ages, although this developed rarely. Early recognition and appropriate antibiotic treatment helps recover acute renal failure secondary to acute pyelonephritis.

Detection of Pyrazinamide Resisitance in Mycobacterium Tuberculosis by Sequencing of pncA Gene / 결핵

BACKGROUND: Examining the biological susceptibility of Mycobacterium tuberculosis to pyrazinamide (PZA) in vitro is very difficult as PZA is inactive under normal culture conditions. The susceptibility test, an enzyme assay for Pzase activity, and a genetic test for pncA gene mutations, were performed in order to predict PZA resistance. METHODS: 28 cultured clinical isolates of Mycobacterium tuberculosis were tested. The biological susceptibility was performed by the absolute concentration method using Lowenstein-Jensen media. The PZase activity was tested by means of Wayne's method. A 710-bp region includes the entire open reading frame of pncA was amplified and sequenced. RESULTS: All six strains with positive PZase activity exhibited no pncA mutations with one strain showing a false resistance in the biological susceptibility test. Among the 22 strains with no PZase activity, 21 exhibited showed pncA mutations. In the biological suscaptibility test, 20 strains were resistant, and one was susceptible, and the other failed to test. The mutation types varied with ten missense, one silent and one nonsense mutation 1 slipped-strand mispairing, and 6 frameshift mutations. Three strains had an adenine to guanine mutation at position - 11 upstream of the start codon. CONCLUSION: The mutation at the pncA promotor region is frequent at -11 upstream position. Automatic sequencing of pncA is a useful tool for rapid and accurate detection of PZA resistant M.tuberculosis, and for demonstrating the epidemiological relatedness of the PZA-resistant M.tubersulosis strains.

A case of pineal germioma presenting with diabetes insipidus / 대한내과학회지

Central diabetes insipidus caused by pineal gland neoplasm is rare. Here, we describe a case of central diabetes insipidus and pineal germinoma with seeding to pituitary stalk along CSF pathway. A 27 year-old male patient was admitted due to polyuria, polydipsia, headache, vomiting, diplopia, and decreased visual acuity for recent two months. Urine osmolality measured after water deprivation was below 100mOsm/kg. However, urine osmolality increasd above 300 mOsm/kg with pitressin administration. Brain MRI showed a 2cm sized mass with seeding into pituitary stalk along CSF in pineal region. Surgical biopsy revealed pineal germinoma. Two cycles of chemotherapy with etoposide and cis-platin were done followed by brain irradiation(2,500cGy). Follow up brain MRI after second chemotherapy showed complete remission. The patient had no neurologic and endocrinologic deficit after the treatment.

Two cases of scrub typhus complicating acute respiratory distress syndrome / 대한내과학회지

Scrub typhus is a zoonotic disease, caused by Orientia tsutsugamushi, and characterized by a typical primary lesion(eschar), rash and non-specific symptoms such as fever and chills, headache, myalgia. Although it is an acute febrile illness, severe complications of this disease are very rare since the introduction of specific antibiotic therapy. The authors report two cases of scrub typhus complicating acute respiratory distress syndrome. Although appropriate diagnosis and treatment were performed, all two patients expired. They were diagnosed as scrub typhus by travel history, clinical manifestations, eschars, serologic test and polymerase chain reaction(PCR).

Telomerase Activity in Primary Lung Cancers / 결핵

BACKGROUND: Telomerase enzyme activity is not detected in most normal cells, a phonomenon believed to be associated with limitations on cellular proliferation. Since this activity is detected in nearly all human tumor, including lung cancers, it has been suggested that telomerase activation may be coupled to acquisition of malignant phenotype. In this study, we determined whether telomerase activity was associated with tumor pathologic stage. METHODS: Primary tumor specimens obtained by bronchoscopic biopsies from 33 patients were analyzed. Telomerase activity was measured by means of a modified Telomeric Repeat Amplication Protocol(TRAP) assay. RESULTS: Telomerase activity was detected in 23 of the 27 non small cell lung cancer and 5 of 6 small cell lung cancer. A few primary tumors did not appear to have detectable telomerase activity. Positive associations were found between the telomerase-positive rate and tumor stage(p<0.05). CONCLUSION: High telomerase activity is detected frequently in primary lung cancers that exhibit high tumor cell proliferation rates and advanced pathologic stage.

Clinical utility of Amplified Mycobacterium tuberculosis Direct Test in the Diagnosis of Pulmonary Tuberculosis / 결핵

BACKGROUND: Acid-fast stain and cultures for diagnosis of pulmonary tuberculosis are primary and essential method, but have their limitation:low sensitivity and time consuming. The objective of this s tudy is comparison of amplified Mycobacterium tuberculosis direct test(MTD) by the conventional AFB smears and cultures in the detection of Mycobacterium tuberculosis in respiratory specimens. METHODS: During the period between November, 1997 and May, 1998 a total of 267 respiratory specimens (sputum 173, bronchial washing 94) from 187 patients suspected pulmonary tuberculosis were subjected to AFB smears, cultures and MTD test. MTD is based on nucleic acid amplification. We compared the MTD with 3% Ogawa culture method. In positive AFB smear and negative MTD specimen, positive culture identification between nontuberculous mycobacterium and M.tuberculosis was assesed by using Accuprobe M.tuberculosis complex probe. In negative AFB smear and negative AFB culture, MTD results are assessed by clinical follow-up. RESULTS: 1) Compared with culture in sputum and bronchial fluid specimens, sensitivity and specificity of MTD in positive AFB smear is 79.7% and 20.0%, sensitivity and specificity of MTD in negative AFB smear specimens is 75.0% and 79.7%. 2) Discrepant analysis is assessed by clinical follow-up and other specimen results beyond study. Culture negative but MTD positive specimens were proved to be true positive and gave MTD sensitivity 79.2%, specificity of 84.4%, positive predictive value 80.5% and negative predictive value 83.2%. 3) 14 out of 31 specimens in negative AFB smear, negative AFB culture and positive MTD showed pulmonary tuberculosis diagnosed on clinical follow-up and sensitivity is 45.2%. 4) 2 out of 13 specimens in positive AFB smear, positive AFB culture and negative MTD diagnosed as nontuberculous mycobacterium by Accuprobe culture. CONCLUSION: This study suggested that MTD in respiratory specimens is simple and rapid diagnostic method, but considered adjuvant method rather than replace the conventional AFB smear and culture.

The Significance of IL-10, IL-12, IFN-gamma and ADA in Tuberculous Pleural Fluid / 결핵

BACKGROUND: Cell mediated immune response mediated by interaction between CD4+ T lymphocytes and macrophagies is thought to play an important role in tuberculous pleurisy. This interaction is dependent on the interplay of various cytokines. The immunologic response of tuberculous pleurisy is thought to depend on the balance between helper T cell(Th1) cytokine Interleukin-12, Interferon gamma and Th2 cytokine IL-4, IL-10. To understand immunologic mechanism in tuberculous pleurisy and evaluate diagnostic value of these cytokines, the concentrations of Th1 cytokine IL-12, IFN-gamma and Th2 cytokine IL-10 were measured in tuberculous pleurisy and malignant pleural effusion group. MATERIAL AND METHODS: The concentrations of IL-b, IL-12 and IFN-gamma were measured by ELISA method in pleural fluids and serums of 20 patients with tuberculous pleurisy and 20 patients with malignant pleural effusion. ADA activities were measured by spetrophotomery in pleural fluids of both groups. RESULTS: In tuberculous pleurisy, the mean concentrations of IL-b, IL-12 and IFN-gamma of pleural fluids showed 121.3+/-83.7 pg/mL, 571.4+/-472.7 pg/mL and 420.4+/-285.9 pg/mL. These were significantly higher than that of serum, 21.2+/-60.9 pg/mL, 194.5 pg/mL, 30.1+/-18.3 pg/mL respectively(p<0.0l). In malignant pleural effusion, the mean concentrations of IL-10, IL-12 and IFN-gamma of pleural fluids showed 88.4+/-40.4 pg/mL, 306.5+/-271.1 pg/mL and 30.5+/-54.8 pg/mL respectively. Compared with that of serum (43.4+/-67.2 pg/mL, 206.8+/-160.6 pg/mL, 14.6+/-3.3 pg/mL), only IL-10 was significantly higher (p <0.001), but IL-12, IFN-gamma were not significant. In tuberculous pleural effusion compared with malignant pleural effusion, the concentration of IL-12, IFN-gamma, ADA were significantly higher (p value 0.046, <0.001, <0.001), but IL-10 was not significant. For differetial diagnosis of tuberculous pleurisy from malignant pleural effusion, using cut-off value of IL-12, IFN-gamma ADA as 300 pg/mL, 100 pg/mL, 45 U/L, the sensitivity/specificity were 60%/70%, 90%/87.5%, 85%/90% respetively. CONCLUSION: In tuberculous pleurisy, IL-10, JL-12 and IFN-gamma were selectively concentrated highley in pleural space than serum. Compared with malignant pleural effusion, IL-12 and IFN-gamma were significantly higher, but IL-10 were not in tuberculous pleural effusion. The results suggest that Th1 pathway contributes to immune resistant mechanism in tuberculous pleurisy. IFN-gamma and ADA revealed useful methods of differential diagnosis in tuberculous pleurisy from malignant pleural effusion.

Analysis of rpoB Gene in Rifampin-Resistant M. Tuberculosis by Direct Sequencing and Line Probe Assay / 결핵

BACKGROUND: The emergence of multidrug-resistant strains of Mycobacterium tuberculosis presents a significant challange to the treatment and control of tuberculosis, and there is an urgent need to understand the mechanisms by which strains acquire multidrug resistance. Recent advances in molecular methods for the detection of M. tuberculosis genetic targets have approached the sensitivity of culture Furthermore the prospect of determining resistance in mycobacteria at the nucleic acid level particulary to first-line drugs like rifampin, isoniazid has provided a glimps of the next generation of sensitivity test for M. tuberculosis. Previous studies in RMP resistant M. tuberculosis have shown that mutation in beta subunit of RNA polymerase is main mechanism of resistance. METHOD: In this study, rpoB gene for the ~3 subunit of RNA polymerase from M. tuberculosis of 42 cultured samples (32 were RMP resistant and 10 were sensitive cases) were isolated and characterised the mutations. Direct sequencing data were compared with the results of INNO-LiPA Line Probe Assay (LiPA, Innogenetics, Belgium), commercial RMP resistance detecting kit using reverse hybridization method. RESULTS: All of the RMP resistant samples were revealed the presence of mutation by LiPA. In 22 samples (68.8%) out of 32 RMP resistant cases, the mutation types were confirmed by the positive signal at one of 4 mutation bands in the strip. The most frequent type was R5 (S53 IL) which were 17 cases (77.3%). Results of direct sequencing were identified the exact characteristics of 8 mutations which were not comfirmed by LiPA. S522W type point mutation and 9 base pair deletion at codon 513-515 were new identified mutations for the first time. CONCLUSION: Mutations in rpoB gene is the main mechanism of RMP resistance in M. tuberculosis and LiPA is a very useful diagnostic tool for the early diagnosis of RMP resistance in M. tuberculosis.