Carbon monoxide poisoning-induced cardiomyopathy from charcoal at a barbecue restaurant: a case report

OBJECTIVE: Acute carbon monoxide poisoning has important clinical value because it can cause severe adverse cardiovascular effects and sudden death. Acute carbon monoxide poisoning due to charcoal is well reported worldwide, and increased use of charcoal in the restaurant industry raises concern for an increase in occupational health problems. We present a case of carbon monoxide poisoning induced cardiomyopathy in a 47-year-old restaurant worker. MATERIALS AND METHODS: A male patient was brought to the emergency department to syncope and complained of left chest pain. Cardiac angiography and electrocardiography were performed to rule out acute ischemic heart disease, and cardiac markers were checked. After relief of the symptoms and stabilization of the cardiac markers, the patient was discharged without any complications. RESULTS: Electrocardiography was normal, but cardiac angiography showed up to a 40% midsegmental stenosis of the right coronary artery with thrombotic plaque. The level of cardiac markers was elevated at least 5 to 10 times higher than the normal value, and the carboxyhemoglobin concentration was 35% measured at one hour after syncope. Following the diagnosis of acute carbon monoxide poisoning induced cardiomyopathy, the patient's medical history and work exposure history were examined. He was found to have been exposed to burning charcoal constantly during his work hours. CONCLUSIONS: Severe exposure to carbon monoxide was evident in the patient because of high carboxyhemoglobin concentration and highly elevated cardiac enzymes. We concluded that this exposure led to subsequent cardiac injury. He was diagnosed with acute carbon monoxide poisoning-induced cardiomyopathy due to an unsafe working environment. According to the results, the risk of exposure to noxious chemicals such as carbon monoxide by workers in the food service industry is potentially high, and workers in this sector should be educated and monitored by the occupational health service to prevent adverse effects.

Comparison of Image Quality of Shoulder CT Arthrography Conducted Using 120 kVp and 140 kVp Protocols

OBJECTIVE: To compare the image quality of shoulder CT arthrography performed using 120 kVp and 140 kVp protocols. MATERIALS AND METHODS: Fifty-four CT examinations were prospectively included. CT scans were performed on each patient at 120 kVp and 140 kVp; other scanning parameters were kept constant. Image qualities were qualitatively and quantitatively compared with respect to noise, contrast, and diagnostic acceptability. Diagnostic acceptabilities were graded using a one to five scale as follows: 1, suboptimal; 2, below average; 3, acceptable; 4, above average; and 5, superior. Radiation doses were also compared. RESULTS: Contrast was better at 120 kVp, but noise was greater. No significant differences were observed between the 120 kVp and 140 kVp protocols in terms of diagnostic acceptability, signal-to-noise ratio, or contrast-to-noise ratio. Lowering tube voltage from 140 kVp to 120 kVp reduced the radiation dose by 33%. CONCLUSION: The use of 120 kVp during shoulder CT arthrography reduces radiation dose versus 140 kVp without significant loss of image quality.

Spinal Cord Glioblastoma Induced by Radiation Therapy of Nasopharyngeal Rhabdomyosarcoma with MRI Findings: Case Report

Radiation-induced spinal cord gliomas are extremely rare. Since the first case was reported in 1980, only six additional cases have been reported.; The radiation-induced gliomas were related to the treatment of Hodgkin's lymphoma, thyroid cancer, and medullomyoblastoma, and to multiple chest fluoroscopic examinations in pulmonary tuberculosis patient. We report a case of radiation-induced spinal cord glioblastoma developed in a 17-year-old girl after a 13-year latency period following radiotherapy for nasopharyngeal rhabdomyosarcoma. MRI findings of our case are described.

Ultrasound and Fluoroscopy-Guided Placement of Central Venous Ports via Internal Jugular Vein: Retrospective Analysis of 1254 Port Implantations at a Single Center

OBJECTIVE: To assess the technical success and complication rates of the radiologic placement of central venous ports via the internal jugular vein. MATERIALS AND METHODS: We retrospectively reviewed 1254 central venous ports implanted at our institution between August 2002 and October 2009. All procedures were guided by using ultrasound and fluoroscopy. Catheter maintenance days, technical success rates, peri-procedural, as well as early and late complication rates were evaluated based on the interventional radiologic reports and patient medical records. RESULTS: A total of 433386 catheter maintenance days (mean, 350 days; range 0-1165 days) were recorded. The technical success rate was 99.9% and a total of 61 complications occurred (5%), resulting in a post-procedural complication rate of 0.129 of 1000 catheter days. Among them, peri-procedural complications within 24 hours occurred in five patients (0.4%). There were 56 post-procedural complications including 24 (1.9%, 0.055 of 1000 catheter days) early and 32 (2.6%, 0.074 of 1000 catheter days) late complications including, infection (0.6%, 0.018 of 10000 catheter days), thrombotic malfunction (1.4%, 0.040 of 1000 catheter days), nonthrombotic malfunction (0.9%, 0.025 of 1000 catheter days), venous thrombosis (0.5%, 0.014 of 1000 catheter days), as well as wound problems (1.1%, 0.032 of 1000 catheter days). Thirty six CVPs (3%) were removed due to complications. Bloodstream infections and venous thrombosis were the two main adverse events prolonging hospitalization (mean 13 days and 5 days, respectively). CONCLUSION: Radiologic placement of a central venous port via the internal jugular vein is safe and efficient as evidenced by its high technical success rate and a very low complication rate.

Case of Breast Cancer in a Neurofibromatosis 2 Patient / 대한내과학회지

Neurofibromatosis 2 is a multiple neoplasia syndrome that is caused by mutations in the NF2 tumor suppressor gene on chromosome 22q12. Bilateral vestibular nerve schwannomas are the distinctive feature of neurofibromatosis 2. There have been no reported cases of breast cancer in patients with neurofibromatosis 2. We recently encountered a case of breast cancer in a 46-year-old woman with neurofibromatosis 2. She had had a palpable right beast mass for the previous year andtinnitus in her left ear for the previous 6 months. She was diagnosed with breast cancer (invasive ductal carcinoma) with metastasis to the lungs, bones and stomach. MRI of the brain revealed nodules in both internal auditory canals, indicating that she was suffering from neurofibromatosis 2. After radiation therapy for compression fractures in T8 and L1, and one cycle of chemotherapy, the patient died of febrile neutropenia and pneumonia.

Cutaneous Metastasis from Lung Cancer: A Single-Institution Retrospective Analysis / 결핵및호흡기질환

BACKGROUND: Lung cancer is responsible for substantial proportions of cutaneous metastasis from internal malignancies. The aim of this study was to evaluate the clinical manifestations and outcomes of cutaneous metastasis in Korean lung cancer patients. METHODS: On a retrospective basis, we analyzed medical records of all patients diagnosed with lung cancer from 2000 to 2006. RESULTS: Cutaneous metastases were found in 10 of 4,385 patients. The number of cases was highest for squamous cell carcinoma. However, there was no metastasis from 754 cases of small cell carcinomas. Cutaneous metastasis was detected during staging work-up in 4 patients and it was the presenting sign of recurrence post-operative in 2 patients. Average time from the diagnosis to discovery of cutaneous metastasis was 16.3 months and median survival was 8.5 months (range, 1.8~19.1 months). CONCLUSION: Physicians should be acquainted with clinical manifestations and outcomes of cutaneous metastasis from lung cancer to detect new, recurrent cancer, or disease progression, and to administer appropriate and prompt management.

Solitary Pulmonary Metastasis of a Thyroid Papillary Microcarcinoma, Masquerading as Primary Lung Cancer

Although pulmonary metastasis of thyroid cancer is not uncommon, it mostly occurs as multiple discrete nodules on the lung parenchyma. Because thyroid cancer presenting with an isolated large lung mass is extremely rare and the diagnosis is frequently based on small pieces of tissue obtained by a fine needle, the wrong diagnosis such as lung cancer is prone to be made. A 60-year-old man was admitted for evaluation of a lung mass detected on chest radiography. Cytological examination of the bronchial washing specimens suggested adenocarcinoma. Surgery for early lung cancer was performed considering that no other abnormalities were found during the work-up that included 18-fludeoxyglucose positron emission tomography computer tomography (18FDG-PET/CT). Unexpectedly, the diagnosis of papillary thyroid cancer with lung metastasis was made, which prompted us to evaluate the thyroid gland and then remove the primary cancer by subsequent operation. Although it is uncommon, physician should be aware of this possibility, which could help to avoid the wrong diagnosis. Here we report on a typical case of solitary pulmonary metastasis of thyroid cancer and we summarize the previously reported cases with a review of the relevant literature.

Clinical Characteristics of 16 Patients with Pituitary Tumor Incidentally Detected by 18F-Fluorodeoxyglucose PET-CT (18F-FDG PET-CT)

BACKGROUND: It is uncommon to unexpectedly discover pituitary tumor as a hypermetabolic lesion on an 18F-FDG PET-CT scan for the evaluation of an unrelated disease when the patient does not show neurological or endocrine signs and symptoms. METHODS: We retrospectively analyzed the medical records of 16 patients with pituitary tumor that was detected incidentally on 18FFDG PET-CT at the Korea Cancer Center Hospital from January 2002 to September 2009. We analyzed their clinical features in detail. RESULTS: On 35,505 18F-FDG PET-CT scans, 16 (0.045%) patients were diagnosed with pituitary incidentaloma. They underwent 18FFDG PET-CT for the evaluation of the state of malignancy. All of them had no signs and symptoms related to pituitary tumor. The average age of the patients was 63.3 +/- 12.0 years (49-85 years). Eleven patients were men and 5 were women. The mean diameter of the tumor was 17.9 +/- 5.7 mm. Most of the pituitary incidentalomas were macroadenoma. The result of tumor morphologic evaluation by the Hardy classification was as follows: 6 grade IV, 1 grade III, 3 grade II and 1 grade I. The mean standardized uptake value of the tumor was 10.6 +/- 6.7. Ten patients had endocrine evaluation and they showed a normal hormone level. Among 16 patients, 4 patients received TSA and they were diagnosed with pituitary adenoma. CONCLUSION: This study showed that pituitary incidentaloma discovered on 18F-FDG PET-CT was extremely rare. It was almost all non-functioning macroadenoma and this showed relatively high FDG uptake.

Newly Developed Weakness of Lower Extremities Despite Improved Brain Metastasis of Lung Cancer after Radiotherapy / 결핵및호흡기질환

An intramedullary spinal cord metastasis (ISCM) rarely develops in systemic cancer but is indicative of a poor prognosis. A 56-year-old man was admitted due to weakness of the lower extremities. He had received radiotherapy 3 months prior for a brain metastasis that had developed 1 year after achieving a complete response from chemotherapy for extended stage small cell lung cancer. Although the brain lesion had improved partially, ISCM from the cervical to lumbar-sacral spinal cords, which was accompanied by a leptomeningeal dissemination, was diagnosed based on magnetic resonance imaging of the spine and cerebrospinal fluid cytology. Finally, he died of sudden cardiac arrest during treatment. This is the first case of ISCM involving the whole spinal segments. Physicians should be aware of the subsequent development of ISCM in lung cancer patients with a previously known brain metastasis who present with new neurological symptoms.

A Comparative Study between Adolescent Acne and Post-adolescent Acne

BACKGROUND: The prevalence of patients over the age of 25 years with acne has significantly increased over the past 10 years. Several etiologic factors such as genetic factor, hyperandrogenism, stress, and cosmetics have been studied. OBJECTIVES: The purpose of this study is to evaluate the differences between adolescent acne and post-adolescent acne, based on the clinical features, asoociated diseased and aggravating factors of 327 acne patients. METHODS: 327 consective patients, first visited to our hospital with clinical facial acne between March 2000 and February 2001, were enrolled. 220 adolescent patients(AP) were under the age of 25 and post-adolescent patients(PP) were over age of 25. RESULTS: 1. In the face, cheeks and forehead in adolescents, chin and cheeks in post-adolescents were predilection sites. The predominant type was a comedonal type in adolescents and a papulopustular type in post-adolescents(P<0.05). Severity of inflammatory type was not different between two groups. Familial factors were important in both groups, but more frequently found in post-adolescents with persistent acne(P<0.05). 2. Rosacea, chloasma, and hyperandrogenic features such as hirsutism and androgenetic alopecia were more frequently observed in post-adolescents. Seborrheic and atopic dermatitis were more frequent in adolescents. Four patients had all the features of chloasma, acne, rosacea, seborrheic dermatitis and hirsutism. 3. Aggravation by weason especially summer, sweating, stress, and cosmetics was more frequent in adolescents. In PP, acne was more frequently aggravated by sunlight, foods and menstrual period. CONCLUSION: Post-adolescent acne was mainly a papulopustular type predominantly located on the chin and cheeks with mild to moderated severity, and family history and hyperandrogenism were strong etiologic factors in persistent acne. Aggravating factors were not significantly different between two group, which suggested cosmetics and stress might not be important in post adolescent acne.

Distribution and Recognition of Skin Diseases in Rural Areas / 대한피부과학회지

BACKGROUND: In many epidemiologic reports of distribution of skin diseases, the outpatients of university hospitals have been the target groups of the analysis. But there has been no epidemiologic study of dermatoses in the field of rural area. OBJECTIVE: The purposes of this study were to investigate the distribution of skin diseases in rural areas and to evaluate the rural population's concept of skin disease and the attitude to their skin problems. METHOD: We analysed the results of interview and responses of questionnaires from 481 residents who visited the local public health centers and the free clinics in the rural areas of Kyonggi-Do and Ulsan city. RESULTS: The results of the study are summarized as follows : 1. Of 481 residents, there were 328 females and 153 males. The mean age was 56.6 years old. The residents over 50 years old formed 73.2 percent of total population. 2. The common dermatoses were tinea pedis, onychomycosis, xerosis, seborrheic keratosis, chloasma, pruritus, hand eczema, contact dermatitis, lentigo, seborrheic dermatitis in order of frequency. 3. The cutaneous fungal infection was the most common dermatoses in each study population. 4. To treat skin diseases, 51.2% of the residents visited the drug store initially. 5. The major reason of not taking dermatological care in the rural population was customary habit. 6. The 39.5% of 238 respondents have used self-treatments, and 15.5% of 90 respondents have experienced side effects of self-treatments. 7. On the question about the negative concepts of dermatoses, 61.7% of 462 respondents agreed to the statement that dermatoses look unclean. 8. Half of the 463 respondents thought that dermatologic medicine was harmful. The 50.6% of the 328 respondents had no specific reason, and 34.1% experienced gastrointestinal trouble. 9. The most favorite type of dermatologic medicine was topical agent, which was preferred especially by the group of respondents using nonmedical service including drug store. CONCLUSION: The distribution of the skin diseases in rural areas was similar to other reported results except the high frequency of cutaneous fungal infection. This research could be a basis on the following epidemiologic studies of the skin diseases in rural areas. It is also suggested that the educational program to improve understanding of skin diseases should be performed in the rural areas.

A Case of Pleomorphic Adenoma Presenting as a Subcutaneous Nodule / 대한피부과학회지

Pleomorphic adenoma is the most common tumor of parotid glands, presented clinically as an asymptomatic slowly growing tumor of pre-or infra-auricular area. In dermatologic department, it can be clinically misdiagnosed as various dermal or subcutaneous tumors. We describe herein a patient who had a pleomorphic adenoma and an epidermal cyst, which appeared similar subcutaneous nodules and diagnosed separately by its characteristic pathologic findings.

Myxoid Myofibromatosis-type Perivascular Myoma Showing Prominent Verocay Body-like Formation

Differential diagnoses showing Verocay body-like formation include schwannoma, palisading myofibroblastoma, palisading cutaneous fibrous histiocytoma, dermatofibroma with myofibroblastic differentiation, leiomyoma, palisaded encapsulated neuroma, and neuroma. A 60-year-old Korean man presented with a 10-year-history of an asymptomatic nodule on the right forearm. Histopathological examination revealed well-circumscribed multi-micronodules with prominent Verocay body-like formation consisted of spindle cells and extensive infiltrate of mutinous materials. The spindle cells were negative for S-100 protein and desmin, but positive for vimentin and a-smooth muscle actin by immunohistochemical staining. The micronodules were lined by CD34 and factor VIII positive endothelial cells. The mutinous materials were stained with alcian blue at pH 2.5, but not at pH 0.5. We diagnose it as myxoid myofibromatosis-type perivascular myoma showing Verocay body-like formation.

PCR Study for Human Herpesvirus 8 in Korean Patients with Several Cutaneous Diseases / 대한피부과학회지

BACKGROUND: The association of Kaposi's sarcoma-associated human herpesvirus, or human herpesvirus 8 (HHV8) with various skin diseases has been described in many reports. However, only 3 human diseases: Kaposi's sarcoma, primary effusion lymphoma, and multicentric Castleman disease were proved to be associated with HHV8. In addition to Karposi's sarcoma, sarcoidosis and Kikuchi's disease were also described to be associated with HHV8. OBJECTIVE: The purpose of this study was aimed at the association of HHV8 with various skin diseases, such as Kaposi's sarcoma, sarcoidosis, and Kikuchi's disease. METHODS: We performed PCR to examine whether the 233-bp segment of the viral DNA of HHV8 was detected in Korean patients with Kaposi's sarcoma, sarcoidosis, Kikuchi's disease, angiosarcoma, and angiolymphoid hyperplasia with eosinophilia. The medical records and histopathological specimens of patients diagnosed at Asan Medical Center from 1989 to 1999 were reviewed. RESULTS: HHV8 DNA sequences were identified in 9 (69%) of sarcoid tissues from 12 patients with sarcoidosis and in all (100%) of from 8 patients with Kaposi's sarcoma but not in 2 tissues from 2 patients with Kikuchi's disease, in 3 tissues from 2 patients with angiosarcoma and 2 tissues from 2 patients with angiolymphoid hyperplasia with eosinophilia. CONCLUSION: HHV8 may be strongly associated with the pathogenesis of Kaposi's sarcoma and sarcoidosis. However, the association with Kikuchi's disease, angiosarcoma, and angiolymphoid hyperplasia with eosinophilia was denied in this study. Further extensive study will be needed.

The Hypereosinophilic Syndrome

BACKGROUND: The hypereosinophilic syndrome(HES) represents a leukoproliferative process likely caused by a number of disorders, all of which are marked by sustained over-production of eosinophils. OBJECTIVES: The purposes of this study were aimed at evaluating the clinical and histopathological characteristics of HES. METHODS: The medical records and hist opathological slides of patients with HES who had skin biopsies performed in our department were reviewed. Criteria for the diagnosis of HES include (1) peripheral blood eosinophilia with eosinophil counts greater than 1,500/L for at least 6 months; (2) no evidence of parasitic, allergic, or other known causes of eosinophilia; and (3) presumptive signs and symptoms of multiple organ involvement. RESULTS: Four male and three female patients were included. HES developed in adulthood or old age (mean, 43.4 years). Because only the patients with cutaneous involvement were included, all the patients showed skin lesions. Heart, liver, stomach, nervous system, lymph nodes, and lung were involved organs in decreasing order of frequency. At the onset of HES, 40 to 80% of white blood cells were eosinophils in peripheral blood. White blood cell count and serum IgE level were elevated in all the tested patients. In six patients (85.7%), the level of serum erythrocyte sedimentation rate was elevated. Persistent hypereosinophilia (>1,500/L) was present for longer than 6 months in all patients. Stool examination and skin test for parasitic infestation all gave negative results. All the patients were not taking any medication. Histopathological examinations revealed perivascular mixed inflammatory cell infiltration; predominantly eosinophils in the stomach, liver, and nerve as well as in the skin. Interestingly, two patients who were presented with skin lesions showed the findings of eosinophilic vasculitis. In these patients, the skin lesions were consisted of Raynaud's phenomenon, digital gangrene, and several erythematous plaques. The most common cutaneous manifestations were papules and nodules on the extremities. The main treatment modality was systemic steroid. Except for one patient presented with central nervous system involvement of HES, all the patients were in a well-controlled state. In one patient with the typical clinical and hematologic features of HES, Hodgkin's disease followed. After the complete remission of Hodgkin's disease with chemotherapy, HES subsided. CONCLUSIONS: HES is a heterogenous collection of disorders marked by hypereosinophilia and organ damage. Most common cutaneous manifestations were papules and nodules on the extremities. Raynaud's phenomenon and digital gangrene can be the primary manifestation of HES in which cases cutaneous lesions showed eosinophilic vasculitis. Five patients (71%) responded well to systemic steroids. HES may be a herald of malignancy such as Hodgkin's disease. Further investigation will be mandatory ro elucidate the etiology and pathogenesis of HES.

A Case of Annular Lichen Planus Associated with Periungual Lesions / 대한피부과학회지

We report a case of annular lichen planus occurred in the hands and feet area, which also showed nail dystrophy and annular or polycyclic plaques on the proximal and lateral nail folds. Annular lesions of lichen planus have been reported mainly in glans penis area of male patients, but predominantly annular variant occurred in other body sites is quite rare and was reported exclusively in black patients. Our case is interesting in that the patient had periungual lesions of lichen planus as well as its rare annular configurations localized to hands and feet.

Clinical Study of 24 Cases with Sweet's Syndrome / 대한피부과학회지

BACKGROUND: Sweet's syndrome is a neutrophilic dermatosis that has various clinical characteristics and is often associated with inflammatory, malignant or autoimmune diseases, so the viral or bacterial antigens and tumor antigens are suspected to play a role in the pathogenesis of Sweet's syndrome. OBJECTIVE: This study was conducted to obtain a better understanding of the clinical features of Sweet's syndrome and estimate the prevalence of malignant associated Sweet's syndrome in Korea. METHODS: Clinical manifestations and histopathologic features of 24 Sweet's syndrome patients were evaluated. RESULTS: The age was varied from 24 to 85 years, averaging 49.3 years. The male to female ratio was 1:2.4 . The site of predilection was the extremities, and the most common involved site was the upper extremities. The associated clinical symptoms were fever, arthralgia, myalgia, and oral ulcer in varying frequencies. In laboratory examinations, there were increased ESR, leukocytosis, and neutrophilia in part of the patients. The associated systemic diseases were found in 58.3% of the patients and hematologic malignancies were the most common with prominent AML-association. The majority of the patients were treated with oral or topical steroids and the recurrences were reported in 50%. CONCLUSION: The associated systemic diseases were presented in 58.3% of 24 Sweet's syndrome patients. And there was high association of Sweet's syndrome and hematologic malignancies, especially AML, as previously reported, which implies the importance of thorough investigation for underlying diseases in the Sweet's syndrome patients.

Folliculosebaceous Cystic Hamartoma / 대한피부과학회지

Folliculosebaceous cystic hamartoma(FCH) is a rare tumor of characteristic clinical and histological features. Histological findings are intradermal cystic structures lined by infundibular epithelium, numerous sebaceous lobules radiating from cystic structures and surrounding stroma composed of mesenchymal changes including variable proportions of fibrous, adipose, vascular and neural tissues. We describe a case of FCH associated with perifollicular mucinosis, which is unusual finding.

Erythroderma: a Clinico-etiologic Study of 39 Patients / 대한피부과학회지

BACKGROUND: Erythroderma may result from different causes. Almost all the published original clinical series of erythroderma originated from western countries. OBJECTIVES: The objective was to evaluate various causes of erythroderma in our environment, frequency, clinical and laboratory findings, and patient evolution. METHOD: We reviewed the clinical and laboratory findings including biopsy materials of 39 patients diagnosed as erythroderma and treated during the last 9 years (from 1989 to 1998). RESULTS: The male-female ratio was 3 to 1. The mean age at diagnosis was 54 years. Drug reaction and undetermined cause were the most frequent cause (30.8%, respectively), followed by the pre-existing dermatoses (28.2%), and malignancies (10.3%). Elevated erythrocyte sedimentation rate was found in 70.4% of the patients. Eight patients were resistant to treatment. In the patients with the persistent erythroderma, leukocytosis, elevated erythrocyte sedimentation rate, and eosinophilia were the common findings. CONCLUSIONS: Half of the patients with the erythroderma of undetermined cause showed the protracted course. Two patients diagnosed as cutaneous T-cell lymphoma and S zary syndrome had the history of generalized erythroderma of more than 3 years. The close follow-up for the erythroderma of undetermined cause with frequent laboratory and histopathological evaluations would be mandatory.