A Case of Sclerosing Encapsulating Peritonitis Presented with Systemic Lupus Erythematosus

Sclerosing encapsulating peritonitis (SEP) is characterized by peritoneal fibrosis and adhesion of the peritoneum with the loops of the small intestine. Although the prevalence is low, most cases are caused by peritoneal dialysis, infection, medication, systemic lupus erythematosus (SLE), and intra-abdominal neoplasm. We describe a 22-year old man who was presented with abdominal pain and distension, which were attributed to SLE with peritonitis. He had no specific history of previous medical illness and peritoneal dialysis. He was treated with intravenous high dose methylprednisolone 1 g/day for 3 days, followed by intravenous methylprednisolone 1 mg/kg daily and immunoglobulin. However, his symptoms did not improve. Eventually, a laparoscopic biopsy was performed for an accurate diagnosis. The histopathologic findings were presented in accordance to the typical characteristics of SEP. In spite of medical treatment, he did not show an improvement of clinical symptoms and radiologic findings. As a result, he died from nutritional deficiency, upper gastrointestinal bleeding, and congestive heart failure.

A Case of Pulmonary Artery Intimal Sarcoma Masquerading as Pulmonary Embolism / 결핵및호흡기질환

Pulmonary artery intimal sarcoma is a rare tumor with no characteristic symptoms. It is frequently misdiagnosed as pulmonary embolism. We report a case of pulmonary artery intimal sarcoma in a 48-year-old man with dyspnea, cough and blood-tinged sputum. He was initially suspected and treated as a pulmonary embolism. Computed tomography of the chest showed filling defects occupying the entire luminal diameter of the right and left pulmonary artery as well as extraluminal extension of the intraluminal mass. Surgical resection of the tumor confirmed pulmonary artery intimal sarcoma. After surgery, he received 8 cycles of combined chemotherapy consisting of doxorubicin and ifosfamide. After 8 cycles, Computed tomography of the chest showed interval regression of the residual tumor. Radiotherapy was done as total 6,000 cGy for 5 weeks, following the 8th chemotherapy. The patient's condition was successfully stabilized with chemotherapy and radiotherapy.

Sudden Pulseless Ventricular Tacchycardia during the Emergence of a Child after the General Anesthesia, and Suspected Viral Myocarditis

A 10-year-old female child was underwent the tonsillectomy and adenoidectomy. She was relieved from the upper respiratory tract infection about 1 week before the operation. Her heart rate was recorded 100 to 110 per minute at the preanesthetic period, and then increased to about 140 per minute during the operation. We speculated that tacchycardia resulted from the inhalation anesthesia of sevoflurane as other common cases, so we didn't consider it as a serious problem. But the taccycardia was not relieved after the termination of anesthesia, and after the extubation, it was severely and rapidly aggravated to the ventricular tacchycardia with the circulatory collapse during the emergence period. After the rapid defibrillation and the chest compression, her resuscitation was successfully finished. We suspected her event was derived from the childhood cardiomyopathy, especially the viral myocarditis. So we reviewed viral myocarditis and focused a new aspect of childhood cardiac disease and screening.

A Case of Swan-Ganz Catheter Malposition: A case report / 대한마취과학회지

A Swan-Ganz catheter is a useful monitoring device for measuring the pulmonary artery pressure, pulmonary capillary wedge pressure and cardiac output, but its insertion brings about many complications, including dysrhythmias, pulmonary artery rupture, thrombosis and infection. We report here on a case of malposition of a Swan-Ganz catheter in a 49-year-old female patient who had undergone liver transplantation due to alcoholic liver cirrhosis.

A Case of Multicentric Reticulohistiocytosis / 대한피부과학회지

Multicentric reticulohistiocytosis is a rare systemic disorder of unknown ethiology, characterized by development of cutaneous papulonodular lesions, and destructive arthritis. Most patients with this condition have been Caucasian. There have only been a few case reports in Korea. However there appears no racial difference in prevalence. We herein report a case of multicentric reticulohistiocytosis in a 47-year-old female, who presented with papulonodules on both hands and had symptoms of a rapidly progressive arthritis. During a trial with methotrexate, cyclosporin, prednisone and NSAID, the patient dropped out of follow-up treatment at the 2nd month, showing no improvement of the condition.

Serologic Test and Therapeutic Drugs of Episcleritis and Scleritis

PURPOSE: To evaluate serologic tests and therapeutic drugs of the patients with episcleritis and scleritis. METHODS: Retrospective chart review was performed for above patients that had been followed from 1986. 8. 8 to 2001. 6. 4. RESULTS: Of a total of 26 patients, 5 patients (38.5%) with episcleritis and 7 patients (53.8%) with scleritis showed seropositivity. Rheumatoid factor (RF) (26.1%) and antinuclear antibody (ANA) (26.1%) were most commonly positive. Eleven patients (84.6%) with episcleritis group were given topical steroid, 3 patients (23.1%) were treated with systemic drugs due to ocular lesions, and 6 patients (46.2%) with systemic drug for underlying systemic diseases. In scleritis group, 11 patients (84.6%) were treated with topical steroid, 2 patients (15.4%) with systemic drugs for ocular lesions, and 7 patients (53.8%) with systemic drug for underlying systemic diseases. An average period of treatment time was 6.4 weeks in episcleritis and 11.1 weeks in scleritis. CONCLUSIONS: Serologic tests help document the underlying disorders in patients with scleritis and in those with persistent or often recurred episcleritis. Also treatment of episcleritis and scleritis requires understanding possible effects of systemic drugs adminstered for underlying disorder on ocular lesion, and requires cooperation with internists and rheumatolgists.

Analgesic Effect of Epidural Clonidine after Cesarean Section / 대한마취과학회지

BACKGROUND: The importance of the intrinsic analgesic properties of the alpha 2-agonist is difficult to establish, but many studies have shown the beneficial effect of epidural clonidine in postoperative pain management. The authors examined the analgesic effect of clonidine, a preferential alpha 2-adrenergic agonist, upon hemodynamics, and side effects during the post-operative period in patients undergoing Cesarean section. METHODS: Sixty healthy parturients undergoing Cesarean section with general anesthesia were divided into two groups as follows: 1) Epidural Morphine group: An initial dose of morphine 3 mg diluted with 10 ml of 0.125% bupivacaine was injected epidurally at time of the peritoneal closure, followed by a continuous epidural infusion of morphine 7 mg and 100 ml of normal saline for the postoperative 2 days. 2) Epidural Clonidine group: An initial dose of clonidine 150 microgram diluted with 10 ml of 0.125% bupivacaine was injected epidurally at time of the peritoneal closure, followed by a continuous epidural infusion of clonidine 1800 microgram and 100 ml of normal saline for the postoperative 2 days. Postoperative analgesia was assessed by recording the VAS (Visual Analogue Scale), PHS (Prince Henry Score) at postoperative 1, 2, 3, 6, 12, 24, and 48 hours. Blood pressure, heart rate, sedation, and side effects were also recorded. RESULTS: There were no statistically significant differences in the VAS and hemodynamic changes between the two groups, but the epidural clonidine reduced the PHS significantly at 1, 2, 3 postoperative hours (P < 0.05). There were less side effects in the cases of epidural clonidine as compared with epidural morphine. CONCLUSION: In comparison to epidural morphine, epidural clonidine produces a similar degree of analgesia but less side effects.

Brain MRI Findings of Neuropsychiatric Lupus

PURPOSE: To evaluate the brain MRI findings in patients with neuropsychiatric lupus. MATERIALS AND METHODS: In 26 patients (M:F=2:24; aged 9 -48 years) in whom the presence of systemic lupus erythematosus was clinically or pathologically proven and in whom neuropsychiatric lupus was also clinically diagnosed, the findings of brain MRI were retrospectively evaluated. MR images were analyzed with regard to the distribution, location, size and number of lesions due to cerebral ischemia or infarction, the presence of cerebral atrophy, and the extent and degree of brain parenchymal and intravascular enhancement. RESULTS: The most common MRI findings were lesions due to cerebral ischemia or infarction occurring in 18 patients (69%), and located within deep periventricular white matter (n=10), subcortical white matter (n=8), the cerebral cortex (n=7), basal ganglia (n=7), or brain stem or cerebellum (n=2). The lesions were single (n=3) or multiple (n=15), and in 17 patients were less than 1 cm in diameter in regions other than the cerebral cortex. In six of these patients, lesions of 1 -4 cm in diameter in this region were combined, and one occurred in the cerebral cortex only. Cerebral atrophy was seen in 16 patients (62%), in ten of whom there was no past history of treatment with steroids for more than six months. In 15 patients (58%), contrast-enhanced MR image revealed diffuse enhancement of the basal ganglia or intravascular enhancement. In no case were MRI findings normal. CONCLUSION: The primary manifestations of neuropsychiatric lupus are multifocal ischemia or infarctions in the cerebral cortex, and subcortical and deep white matter, and the cerebral atrophy. Contrast-enhanced MR images also demonstrated diffuse enhancement of the basal ganglia and intravascular enhancement, both thought to be related to the congestion due to the stagnation of cerebral blood flow.

Brain MRI Findings of Neuropsychiatric Lupus

PURPOSE: To evaluate the brain MRI findings in patients with neuropsychiatric lupus. MATERIALS AND METHODS: In 26 patients (M:F=2:24; aged 9 -48 years) in whom the presence of systemic lupus erythematosus was clinically or pathologically proven and in whom neuropsychiatric lupus was also clinically diagnosed, the findings of brain MRI were retrospectively evaluated. MR images were analyzed with regard to the distribution, location, size and number of lesions due to cerebral ischemia or infarction, the presence of cerebral atrophy, and the extent and degree of brain parenchymal and intravascular enhancement. RESULTS: The most common MRI findings were lesions due to cerebral ischemia or infarction occurring in 18 patients (69%), and located within deep periventricular white matter (n=10), subcortical white matter (n=8), the cerebral cortex (n=7), basal ganglia (n=7), or brain stem or cerebellum (n=2). The lesions were single (n=3) or multiple (n=15), and in 17 patients were less than 1 cm in diameter in regions other than the cerebral cortex. In six of these patients, lesions of 1 -4 cm in diameter in this region were combined, and one occurred in the cerebral cortex only. Cerebral atrophy was seen in 16 patients (62%), in ten of whom there was no past history of treatment with steroids for more than six months. In 15 patients (58%), contrast-enhanced MR image revealed diffuse enhancement of the basal ganglia or intravascular enhancement. In no case were MRI findings normal. CONCLUSION: The primary manifestations of neuropsychiatric lupus are multifocal ischemia or infarctions in the cerebral cortex, and subcortical and deep white matter, and the cerebral atrophy. Contrast-enhanced MR images also demonstrated diffuse enhancement of the basal ganglia and intravascular enhancement, both thought to be related to the congestion due to the stagnation of cerebral blood flow.

Detection of Lumbar Disc Herniation after General Anesthesia: A case report / 대한마취과학회지

Reports of neural and non-neural injury associated with anesthesia have appeared in the medical literature. The majority of these injuries were due to improper patient positioning on the operating table and mostly correlated with the duration of surgery. We observed a case of lumbar disc herniation that was detected after general anesthesia in the traditional supine position. A 34-year-old woman underwent an operation for removal of uterine myoma. She complained of newly developed severe back pain that radiated down the lower right leg. HIVD L4~5 confirmed by lumbar MRI at POD 4th. We felt the cause of HIVD was related to the supine position or preexisting back pain with HIVD was exacerbated during surgery. This is possible to be prevented by evaluating the patient's postural limitation during the visit before anesthesia, padding under lumbar area and a more appropriate position to suit the patient needs for example, Lawn-chair position. The patient was treated with epidural injection of steroid at pain clinic.

Detection of Lumbar Disc Herniation after General Anesthesia: A case report / 대한마취과학회지

Reports of neural and non-neural injury associated with anesthesia have appeared in the medical literature. The majority of these injuries were due to improper patient positioning on the operating table and mostly correlated with the duration of surgery. We observed a case of lumbar disc herniation that was detected after general anesthesia in the traditional supine position. A 34-year-old woman underwent an operation for removal of uterine myoma. She complained of newly developed severe back pain that radiated down the lower right leg. HIVD L4~5 confirmed by lumbar MRI at POD 4th. We felt the cause of HIVD was related to the supine position or preexisting back pain with HIVD was exacerbated during surgery. This is possible to be prevented by evaluating the patient's postural limitation during the visit before anesthesia, padding under lumbar area and a more appropriate position to suit the patient needs for example, Lawn-chair position. The patient was treated with epidural injection of steroid at pain clinic.

Incidence of Cesarean Section Following a Continuous Lumbar Epidural Analgesia for Labor Pain / 대한마취과학회지

BACKGROUND: This retrospective study was subjected to evaluate a causal relation in the incidences of Cesarean section with or without epidural analgesia during labor. METHODS: All of the subjects was divided into two groups which consisted of 394 cases wanted epidural analgesia as Epidural group and 2938 cases unwanted it as Non-epidural group. Continuous lumbar epidural analgesia was performed at L3-4 interspace with catheter advancing 3 cm cephalad when cervix was dilated to at least 3~5 cm and then patient was placed lateral decubitus or sitting posture. 0.125% bupivacaine 10 ml was injected initially via the epidural catheter and then followed by a mixture (10 ml) of bupivacaine 16.7 mg and fentanyl 16.7 microgram hourly to be infused continuously. The data were analysed using Pearson's x2 test with p<0.05 taken as a significant difference. RESULTS: The incidence of normal spontaneous vaginal delivery and Cesarean section, the cause of alteration to Cesarean section, and gestational frequency followed by Cesarean section rate showed no significant difference between two groups. The occurrence of neonate below 7 points of Apgar score at one and five minute after Cesarean section was rather more in Non-epidural group (p<0.05) than that in Epidural group. CONCLUSION: It is concluded that the continuous lumbar epidural analgesia with the dose of bupivacaine and fentanyl as mentioned above does not affect to Cesarean section rate during labor, which provides safe and effective for labor pain control.

The Effect of Corticosteroids on the Recovery Index of Neuromuscular Blockade / 대한마취과학회지

Several investigators have described an interaction between muscle relaxants and corticosteroids which have showed different results. The exact mechanism of this section is not clear and there conflicting results have further confusion. For the confirmation on how to interact these two drugs in patients without influencing factors to the neuromuscular transmission, corticosteroids(hydrocortisone, methyl prednisolone) 0.5mg/kg and 5.0 mg/kg mixed in 20ml of normal saline with micro-dose of various muscle relaxants(vecuronium 0.1mg/kg/30, d-Tubocurarine 0.4mg/kg30, succinylcholine 1mg/kg/30) were administered respectively into the vein at the distal portion of a pneumatic tourniquet applied on the upper arm with higher pressure than arterial pressure. This was to study the dose response according to recovery time between the experimental troup and the control group. Neuromuscular block was measured by recording the twitch response following ulnar nerve stimulation by EMG(ABM, Datex Co., 2Hz 30 mA supermaximal voltage). And at over 95% depression of the twitch height, following administration of muscle relaxants alone(control group) or muscle relaxants combined with corticosteroids(study group), the tourniquet was released, and recovery time from 25% to 75% recovery of twitch height was measured according to recovery index(RI). The results obtained were as follows: 1) In the group which 0.5mg/kg of hydrocortisone was administered. the RI of vecuronium and d-tubocurarine was shorten to 3.47+/-1.43 and 9.30+/-1.48 minutes, and in hydrocortisone 5.0mg/kg, was prolonged to 12.30+/-2.18 and 17.96+/-0.62 minutes, compared with control group(8.08+/-1.48 in vecuronium and 13.43+/-2.32 in d-Tubocurarine). 2) Methyl prednisolone also tended to short the RI in 0.5 mg/kg of corticosteroids and to prolong in 5.0 mg/kg, but not significant. 3) Corticosteroids not to depend on dose prolonged the RI from succinylcholine induced neuromuscular blocks. 4) Plasma cholinesterase values following injection of hydrocortisone 0.5mg/kg and 7.0mg/kg were not changed significantly. 5) Hydrocortisone alone had significant effect on twitch tension, increased in dose of 0.5mg/kg and depressed in dose of 5.0mg/kg. Conclusively, in the interaction between corticosteroids and muscle relaxants, a combined effect of antagonism in small dose and enhancement in large dose of corticosteroids to non-depolarizing neuromuscular blocking action and a potenciated effect to depolarizing neuromuscular blocking action, seems to be possible. We recommend careful monitoring of neuromuscular transmission in patients receiving corticosteroids when neuromuscular blocking agents in used for muscle relaxation.

The Effect of Regional Hypothermia of Neuromuscular Transmission / 대한마취과학회지

To determine the influence of hypothermia on the neuromuscular transmission, 25 patients were studied during O2-N2O(50%)-enflurane(1-2%) anesthesia without any muscle relaxants. Ventilation was controlled to maintain normocapnia and neuromuscular transmission was monitored by delivering train-of-four(TOF) stimuli to the ulnar nerve at wrist(Accelograph, Biometer) while the circulation to the ipsilateral forearm was occluded by tourniquet for 20 minutes. Regional hypothermia was induced to the isolated arm by intravenous injecton of 20ml normal saline cooled by 10degrees C and by surface cooling with ice pack in 15 patients (hypothermia group). To compare the neuromuscular transmission in hypothermia with 10 patients in normothermia whose temperature were maintained at normothermia by intravenous injection of 20ml normal saline of 36degrees C(normothermia group), TOF response was measured following temperature gone down. The results obtained were as follows. First twitch height of TOF response(T1) was not changed, significantly in normothermia group for 20 minutes. In hypothermia group, T1 was decreased insignificantly until the temperature fell to 32degrees C, but it began to decrease significantly from below 31degrees C as compared to normothermia group, e. g., 82.4+/-31.2/o(p<0.05), 73.1+/-29.6%(p<0.0l), 53.2+/-14.4%(p<0.01), 38.7+/-18.7% (p<0.01), and 35.9+/-16.3%(p<0.01) at 31, 30, 29, 28 and 27C respectively. T4 ratio was not affected in both normothermia and hypothermia groups. In 5 eases of 15 hypothermia patients, we observed transient increase of T, under the moderate hypothermia(35~32degrees C) before markedly diminution of T, under the profound hypothermia(< or =31degrees C)

Plasma Cholinesterase Activity and Reaction of Succinylcholine in Late Pregnancy / 대한마취과학회지

Plasma cholinesterase (ChE), an enzyme produced by the liver, rapidly hydrolizes succinylcholine. In the presence of low enzymatic activity, the rate of destruction of succinylcholine is diminished and it may result in an undesirably long duration of paralysis following succinylcholine administration. There are many reports that a significant fall in plasma ChE activity was shown to occur during pregnancy and in the immediate postpartum period. The present study was designed to compare the plasma ChE activity and the reaction of succinylcholine in 27 healthy nonpregnant women with that in 30 pregnant women undergoing elective caesarean section. Before induction of anesthesia, venous blood was taken for the measurement of plasma ChE activity, which was assayed by a colorimetric method, and the duration of action, recovery index and TOF ratio of succinylcholine were measured using ABM (Anesthesia and Brain activity Monitor, Datex Co.). The results were as follows: 1. Plasma ChE aetivity in pregnant women was lower than in nonpregnant women but was not statistically significant. 2. With respect to the duration of action, recovery index and TOF ratio on the 25 and 75% recovery of first twitch height, there were no significant differences between pregnant and nonpregant women.