Clinical Features of Acute Renal Failure Secondary to Acute Pyelonephritis: Comparison with Uncomplicated Pyelonephritis / 대한신장학회잡지

BACKGROUND: Acute pyelonephritis (APN) is an unusual cause of acute renal failure (ARF) in patients without urinary obstruction and other predisposing conditions. Therefore, in the differential diagnosis of ARF, APN is rarely considered. METHODS: We retrospectively analyzed the data from the patients with ARF secondary to APN (ARF group, n=8) with normal renal anatomy and no known predisposing conditions which lead to ARF during the course of acute bacterial pyelonephritis, and investigated the differences of clinical parameters to the patients with uncomplicated APN (control group, n=20). RESULTS: Female were predominant in both groups. The mean age was 49.2+/-14.4 years in control group and 56.3+/-16.4 years in ARF group. On admission, the body temperature was 37.5+/-1.14degrees C in control group and 36.62+/-0.32degrees C in ARF group (p= 0.003). The days of pyuria, duration days of costovertebral angel (CVA) tenderness and hospitalization days were significantly prolonged in ARF group. CVA tenderness was unilateral in 65% of control group and bilateral in 65% of ARF group. Amounts of daily urine protein excretion were 0.15+/-0.48 gm/ day in control group and 2.99+/-2.89 gm/day in ARF group (p=0.001). Creatinine clearance and FeNa were 24.04+/-15.98 mL/min and 2.80+/-2.68 in patients group, respectively. Development of ARF had positive correlation with the duration of pyuria (r=0.579, p< 0.01), amounts of daily urine protein excretion (r=0.854, p< 0.01), duration of CVA tenderness (r=0.461, p< 0.05) and had a negative correlation with body temperature (r=-0.402, p< 0.05). CONCLUSION: APN is a rare but important cause of acute renal failure. Patients with ARF secondary to APN seems to have more prolonged period of pyuria and CVA tenderness, apyrexia and excrete more protein in urine than patients with uncomplicated APN. Adequate treatment of the bacterial infection by prompt antibiotic treatment may lead to full recovery of renal function.

Severe hypokalemia in internal medicine hospitalized patients / 대한내과학회지

BACKGROUND: Serum potassium level assessment is one of the commonly requested laboratory tests. Hypokalemia is defined as a serum potassium level of less than 3.5 mEq/L. It can be potentially life-threatening when severe, due to its association with cardiac arrhythmia and sudden deaths. The aim of our study is to determine the prevalence and to define clinical characteristics of severe hypokalemia in internal medicine hospitalized patients. METHODS: From December 1999 to June 2000, the group with at least one recorded plasma potassium concentration of less than 3.0 mEq/L was selected in department of internal medicine, Pusan national university hospital. Routine records of age, sex and prevalence was collected. Severe hypokalemia is defined as a serum potassium concentration less than 2.6 mEq/L. This patients were retrospectively studied for discharge diagnosis, medications prescribed before and during hospital stay, hospital course and laboratory findings. RESULTS: There were 7.52% (235/3124) with at least one recorded potassium level of less than 3.0 mEq/L. Severe hypokalemia were 75 patients (2.4%). It were more likely to be female, but statically insignificant. Of the 75 patients, 59 patients (77.3%) had hypokalemia during hospitalization. Gastrointestinal loss of potassium was only 13.8% of the patients. The main causes were combination of iatrogenic factors, including the adminstration of intravenous fluids with insufficient or no potassium, malnutrition, and several drugs. The discharge diagnosis included infection 20 patients (26.6%), malignancy 19 patients (25.3%), gastointestinal disorders 8 patients (10.6%). And each of cardiovascular, respiratory and renal disorders have 7 patients (9.3%). In-hospital mortality was 34.6% (26/75) in severe hypokalemia. Compared to the alive group, death group showed statically significant decrease in serum albumin concentration (p<0.05). CONCLUSION: Severe hypokalemia is fatal electrolyte disorder. The most frequent cause of this lethal condition is drug therapy and intravenous fluids with insufficient or no potassium replacement. It can be prevented by regular potassium monitoring and appropriate potassium supplementation in risky hospitalized patients.

Nutcracker syndrome: treatment with an intravascular stent / 대한내과학회지

The nutcracker syndrome refers to compression of the left renal vein between the aorta and the superior mesenteric artery, which results in renal vein and left gonadal vein varices. This is an unusual, but well accepted cause of hematuria. We report a case of the nutcracker syndrome which is diagnosed by CT angiography before venography and pressure measurement of the left renal vein and managed by intravascular stent placement. A 47-year-old female patient was presented with gross hematuria. Urinalysis revealed hematuria with only 1% of dysmorphism. Abdominal spiral CT and 3D CT angiography revealed compression of the left renal vein between the aorta and superior mesenteric artery because of an acute branching angle of superior mesenteric artery from the aorta. Renal venography showed compression of the left renal vein and collateral circulations to the left ovarian vein and lumbar vein. The pressure gradient between the left renal vein and inferior vena cava was 4 mmHg. Intravascular stent was placed in this patient. We conclude that in patients with the nutcracker syndrome, CT angiography could be considered before venography and venous pressure measurements. When this syndrome leads to clinical symptoms, Intravascular stent placement should be considered. Well designed stent offers minimal invasiveness and physiologic relief as in the present case.

Asymptomatic Bacteriuria in Patients with Chronic Renal Failure / 대한신장학회잡지

BACKGROUND: In patients with chronic renal failure, infection is caused by altered host defense mechanism, and contributes significantly to their morbidities and mortalities. Especially, urinary tract infection often occurs in patients with chronic renal failure and is due to azotemia, infrequent voiding, low urinary flow rate and urinary concentration defects. This study was designed to compare the incidence of asymptomatic bacteriuria with chronic renal failure with that of normal control group. We also investigated whether risk factors for urinary tract infections in patients with chronic renal failure are similar to those in normal control groups. METHODS: 34 patients (M : F=13 : 21) with chronic renal failure and 30 normal control groups (M : F= 11 : 19) were evaluated in the Pusan National University Hospital from January 2001 through December 2001. Etiology of chronic renal failure included diabetes mellitus (n=16, 47.1%), hypertension (n=14, 41.2%) and glomerular diseases (n=4, 11.7%). 25 patients were treated with hemodialysis and 5 patients were treated with peritoneal dialysis. Others (n=4) were not treated with dialysis. Clean-catch, first voided urine was collected in the morning and examined by routine urinalysis and urine culture. RESULTS: 7 of 34 (20.6%) patients with chronic renal failure were positive in urine cultures and only one of 30 (3.3%) from the normal control group were positive. E. coli (n=2), Acinetobacter baumanii (n=2), Enterococcus spp. (n=2), S. aureus (n=1), P. aeruginosa (n=1), S. epidermidis (n=1) and Str. viridans (n=1) are cultured from urine specimens. There was a significant difference between the incidence of asymptomatic bacteriuria in patients with chronic renal failure and that of normal control group. But there was no significant difference in the presence of bacteriuria according to sex, age, etiology of renal failure, dialysis modality and pyuria. CONCLUSION: Patients with chronic renal failure have higher frequency of asymptomatic bacteriuria and pyuria than healthy subjects and tend to lead to symptomatic urinary tract infections.

The correlation of microalbuminuria and glomerular filtration rate in normotensive patients with type 2 diabetes mellitus / 대한내과학회지

BACKGROUND: Diabetic nephropathy is one of the major causes of end-stage renal disease. Microalbuminuria predicts not only progressive renal disease, but also increased cardiovascular morbidity and mortality. But, the relationship between urinary albumin excretion rate (UAER) and glomerular filtration rate (GFR) remains an unresolved issue. In order to investigate the early renal function abnormalities, UAER and GFR were assessed and their relationship was examined in normotensive patients with type 2 diabetes mellitus (DM). METHODS: Between January 1997 and June 2001, in a cross sectional study of 112 normotensive patients with type 2 DM not showing overt proteinuria and thirty healthy subjects served as control group. According to UAER, type 2 DM patients were divided into normoalbuminuria group and microalbuminuria group. The GFR was measured using 99mTc-DTPA renal scan. Clinical values in type 2 DM patients and control subjects were compared using one-way analysis of variance (ANOVA) with Scheffe's F test. In type 2 DM patients, Univariate Chi-square analysis was used to evaluate the prevalence of diabetic retinopathy and the differences in anti-diabetic treatment. Pearson correlation coefficients were used to demonstrate a strength of an association between UAER and other variables including GFR. RESULTS: Three groups were well matched with regard to gender, age and body mass index. There were no significant differences in disease duration and anti-diabetic treatment in type 2 DM patients. The GFR in microalbuminuric patients was significantly higher than in normoalbuminuric patients (124.0 17.6 vs 102.9+/-15.5 mL/min/1.73 m2, p<0.05). The prevalence of diabetic retinopathy in microalbuminuric patients was significantly higher than in normoalbuminuric patients (53.8% vs 24.7%, p<0.05). Only there was significant positive correlation between log UAER and GFR (r=0.303, p<0.05). CONCLUSION: As in type 1 DM patients, there was a significant relationship between UAER and GFR in normotensive type 2 DM patients without overt proteinuria.

A Case of Neurofibromatosis Type 1 Associated with Minimal Change Disease / 대한신장학회잡지

Neurofibromatosis type 1 is the most common neurocutaneous disorders and affects between 1/2,000 and 1/4,500 people. This occurs at any age and is hereditary disease with autosomal dominant fashion. Renovascular hypertension is major form of renal manifestation of the disease. There are few reported cases in Japan and Hungary of Recklinghausen's neurofibromatosis with several glomerular lesions but their relationship is not apparent. A 21-year-old man was admitted to the hospital because of general edema. On admission, the blood pressure was 130/ 80 mmHg and general edema was noted. He had a plexiform neuroma on right flank and multiple cafe- au-lait spots on chest and extremites. Laboratory findings were as follows : Hemoglobin 14.2 g/dL, AST 28 IU/L, ALT 12 IU/L, albumin 1.2 gm/dL, total cholesterol 533 mg/dL, urinary protein 4.0 gm/ day, C3 86.6 mg/dL, C4 19.9 mg/dL, HBs Ag/Ab (+/-), HBe Ag/Ab (+/-), HCV Ab (-), HBV DNA probe 6,000 pg/mL. Renal biopsy was performed and the histological findings were compatible with minimal change disease. The immunohistochemical method revealed that HBsAg was negative. We experienced a case of minimal change disease concurrent with Neurofibromatosis type 1, but their relationship is not clear. We report this case with a brief review.

The changes in cardiac dimensions and function in patients with end stage renal disease undergoing hemodialysis

BACKGROUND: It is absolutely necessary to evaluate cardiac function on starting and during hemodialysis in patients with end stage renal disease. In this study, we tried to determinate the changes of cardiac function associated with hemodialysis. METHODS: Twenty patients with end stage renal disease, who had been in a hemodialysis program from February, 1997 to August, 1999 in Pusan National University Hospital, were enrolled. They were examined with echocardiography and gated blood pool scintigraphy on starting hemodialysis and after follow-up. The data were analyzed by paired t-test. RESULTS: The patients were 46.2 +/- 16.8 years old and male to female ratio was 8 : 12. The underlying diseases were diabetes mellitus (n=10), hypertension1), glomerulonephritis2) and others1). The duration of symptoms associated with end stage renal disease and underlying diseases was 3.4 2.6 years and the duration of hemodialysis was 13.8 7.0 months. The LVEDID, LVESID and RVC decreased significantly (-6.10, -7.80 and -20.00%, respectively, p 0.05). In ten cases associated with diabetes, LVEDID decreased (-7.90%, p < 0.05). In twelve cases associated with cardiac diseases, LVEDID and LVESID decreased (-8.60 and -10.50%, respectively, p < 0.05). In four cases associated with diabetes without cardiac diseases, LAD decreased (-5.10%, p 0.05) and in four cases associated with cardiac diseases without diabetes there were no significant changes in cardiac dimensions and EF. In seven cases associated with diabetes and cardiac diseases, LVEDID decreased (-10.50%, p < 0.05). The EF on gated blood pool scintigraphy decreased (-0.9%, p < 0.05) as a whole while it increased (5.90%, p < 0.05) in the cases associated with diabetes and cardiac diseases. CONCLUSION: During the early hemodialysis stage of end stage renal disease, we found a change of concentric left ventricular hypertrophy and relatively preserved left ventricular function. Furthermore, we can expect that adequate hemodialysis - with dry weight as low as possible - may prevent progression to eccentric left ventricular hypertrophy and dilated cardiomyopathy.

Serum Levels of VEGF in IgA Nephropathy / 대한신장학회잡지

BACKGROUND: Vascular endothelial growth factor (VEGF) is a potent enhancer of microvascular permeability and a selective endothelial cell growth factor. In human kidney, VEGF is expressed mainly in glomerular visceral epithelial cells. We investigated the relationship between serum levels of VEGF and factors reflecting the severity of disease including histological patterns in order to elucidate the relevance of VEGF in the pathogenesis of IgA nephropathy. METHODS: Serum VEGF was studied using a sandwich ELISA from 21 patients with IgA nephropathy. Histological patterns are classified to 5 grades by WHO classification and frequencies of crescent and glomerular sclerosis, degree of interstitial fibrosis were recorded. Serum concentrations of creatinine, albumin, IgA, amounts of 24 hour urine protein excretion, and creatinine clearances are also evaluated. RESULTS: Serum VEGF levels were significantly correlated with histological grade(r=0.471, p < 0.05), frequency of cellular crescent(r=0.485, p < 0.05), degree of interstitial fibrosis(r=0.562, p < 0.01), and 24 hour urine protein excretion(r=0.439, p < 0.05), and inversely with serum albumin concentration(r=-0.594, p < 0.01). Studies in 17 patients without crescent formation revealed that only serum albumin concentration showed significant correlation with serum VEGF level. CONCLUSION: Serum VEGF concentration is mainly correlated with cellular crescent formation reflecting activity of the disease rather than chronic structural changes such as glomerular sclerosis or interstitial fibrosis. Elevated serum VEGF concentration seems to be due to the release of relatively large amounts of stored VEGF from damaged visceral epithelial cells. Serum VEGF concentration may be a useful marker to evaluate the degree of acute renal injury, especially cellular crescent formation.

The Correlation between Relative Renal Uptake of (99m)Tc-DMSA Renal Scan and Glomerular Filtration Rate in Patients with Reduced Renal Function / 대한신장학회잡지

BACKGROUND: Glomerular filtration rate(GFR) is an important parameter for the evaluation and monitoring of renal function. The aim of this study was to investigate the correlation between the relative 1 hour uptake of (99m)Tc-DMSA renal scan(DMSA- %uptake, TRUR) and GFR which was estimated by (99m)Tc-DTPA, serum creatinine and 24 hour-urinary creatinine excretion. METHODS: Between January 1998 and March 2001, 65 patients had undergone (99m)Tc-DMSA renal scan, (99m)Tc-DTPA renal scan, serum creatinine and 24 hour-urinary creatinine excretion. Of them, 42 patients had moderately or severely reduced renal function(DTPA-GFR 0.05). In group B, TRUR (mean+/-S.D. 16.3+/-7.4%) was significantly correlated with DTPA-GFR(r=0.731, p < 0.01). In both group, serum creatinine, Ccr and C and G Ccr were significantly correlated with TRUR. CONCLUSION: Although the relative 1 hour uptake of the (99m)Tc-DMSA renal scan, as a method of renal cortical image could not estimate the true GFR, it showed a good correlation with GFR in patients with moderately reduced renal function. (99m)Tc-DMSA renal scan seems to be helpful to evaluate the renal function in patients with moderately reduced renal function.

A Case of Dermatomyositis Associated with Thyroid Cancer / 대한류마티스학회지

Dermatomyositis is an autoimmune connective tissue disorder characterized by symmetrical proximal muscle weakness due to chronic inflammation and degeneration of skeletal muscle. Cancer occurs in patients with dermatomyositis with a frequency estimated between 15~20%. The common sites of malignancy are stomach, breast, ovary, lung and etc. The cases that have been reported so far are dermatomyositis associated with lymphoproliferative disorder and cancer of colon, liver, pancrease, pharynx, uterine cervix, testis, kidney. But dermatomyositis associated with thyroid cancer has not been reported in Korea. We, the authors, experienced a case of dermatomyositis associated with the thyroid cancer and as such we are reporting the case with literature reviews.

The Effects of Interleukin-17 on Production of Vascular Endothelial Growth Factor in Cultured Rheumatoid Arthritis Synoviocytes / 대한류마티스학회지

OBJECTIVE: To investigate the the effects of interleukin-17 (IL-17)on the production of vascular endothelial growth factor (VEGF)from cultured rheumatoid arthritis synoviocytes. METHODS: Fibroblast-like synovial cells(FLS)were prepared from the synovial tissues of rheumatoid arthritis patients and cultured in the presence of IL-17, IL-17 with or without transforming growth factor-beta(TGF-beta),tumor necrosis factor-alpha(TNF-alpha)and interleukin-1 beta(IL-1 beta).VEGF levels were determined in the culture supernatants by sandwitch ELISA. RESULTS: Stimulation of FLS by serial concentration of IL-17,TGF-beta,TNF-alpha,IL-1 beta increased the production of VEGF by 2.1-2.7,2.2-3.0,2.0-2.9,2.3-3.1 fold over the constitutive levels of unstimulated FLS.Stimulation of FLS by IL- 17 with TGF-beta or TNF-alpha or IL-1 beta also increased the production of VEGF accord-ing to culture periods by 1.6-1.8,1.1-1.9,1.5-1.7 fold over the levels stimulated with TGF-beta or TNF-alpha or IL-1 beta,respectively.This results indicated that IL-17 increased the effect of TGF-beta,TNF-alpha,IL-1 beta on FLS,leading synergistic enhancement of VEGF production. CONCLUSION: IL-17 may be involved in the neovascularization in rheumatoid synovitis by enhancing the production of VEGF.

A case of thrombotic thrombocytopenic purpura in systemic lupus erythematosus / 대한내과학회지

Thrombotic thrombocytopenic purpura (TTP) rarely may be seen in association with autoimmune processes such as scleroderma, rheumatoid arthritis, polyarteritis nodosa, Sj gren's syndrome, and systemic lupus erythematosusus (SLE). The diagnosis of TTP as a syndrome distinct from SLE may be challenging, because both processes may present with some or all elements of the classic pentad considered pathognomonic of the former: microangiopathic hemolytic anemia, fever, thrombocytopenia, neurological deficits, and renal abnormalities. We describe a patient with synchronous TTP and SLE, and review the literature.

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.

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).

Predictive Factors of Acute Renal Failure in Sepsis: APACHE III Prognostic System and Liano System / 대한신장학회잡지

Uncontrolled infection quite often 1eads to systemic inflammatory response syndrome and multi-organ dysfunction syndrome. Despite advances in medical knowledge and technology, the mortality of patient with sepsis is still 35-60%, and even reach up to 50-90% in septic patients having acute renal failure. The purpose of this study was to examine the characteristics and predictive factors of progression to acute renal failure(ARF) in sepsis. We analyzed the bacteriologic and laboratory data of 54 admitted patients with SIRS (systemic inflammatory response syndrome) at Pusan National University Hospital from July 1997 to July 1999 (ARF 23 vs non-ARF 31). Multiple factor which may influence mortality and progression to AEK in sepsis, were evaluated and measured on admission day. The following of results, 1) Of the 54 patients, 23 were ARF group and 31 were non-ARF group. Mean age were, 52 years and 51 years. The mortality of ARF group and non-ARF group were 78% and 23%, Urine output, albumin, cholesterol, mean arterial blood pressure and evidence of underlying disease were not statistically different in each group. 2) Although the sources of sepsis could not identified in 9% (ARF), 23% (non-ARF), the others had the primary site of infections: gastrointestinal tract (35% vs 29%), lung (30% vs 19%), genitourinary tract(9% vs 13%), skin (17% vs 16%). 3) Although statistically not different, gram-positive bacterial infection was more common in ARF group (mainly staphylococcus aureus). Culture negative results were 4 patients (ARF), 1 patient (non-ARF). 4) APACHE III score in ARF group was higher than non-ARF group (48.1+/-16.5 vs 30.2+/-15.6). Liafio score in ARF group was higher than non-ARF group (39.1+/-13.0 vs 28.9+/-8.3). 5) APACHE III score and Liailo score in non-survivors were higher than survivors(APACHE III score: 48.6+/-15.3 vs 28.1+/-14.0, Liaho score:37.9+/-12.0 vs 29.4+/-9.2) 6) APACHE lII system was positively correlated with Liaho system (r=0.512, p=0.001). In conclusion, APACHE III system and Liaho system were significant predictors of progression to ARF and mortality in sepsis. In the future, prospective and multicenter studies are required to improve the method of treatment and the prognosis in sepsis.

A case of candida fungemia in acute pancreatitis and hepatitis associated with typhoid fever / 대한내과학회지

Typhoid fever is a bacteremic disease and many organs, including intestine, liver, bone, lung, thyroid, kidney, spleen, heart and pancreas may be invaded by the organism. Acute pancreatitis associated with typhoid fever sometimes needs prolonged total parenteral hyperalimentation and antibiotic treatment. Systemic Candida infections are usually encountered as opportunistic infections in a setting of immunologic depression. The authors report a case of Candida parapsilosis fungemia associated parenteral nutrition in acute pancreatitis associated with typhoid fever. A 17 year-old man was transfered to Pusan national university hospital on May 4th, 1998 under diagnosis of salmonella sepsis. High fever, nausea, vomiting and diarrhea developed 10 days before entery. On admission, serum amylase, lipase and transaminase showed elevation. The patient was treated with antibiotics(ceftriaxon) and total parenteral hyperalimentation was done under diagnosis of acute pancreatitis and hepatitis associated with typhoid fever. On 3rd hospital day, body temperature returned to normal but abdominal pain, nausea and vomiting continued. On 18th hospital day, high fever recurred and ceftriaxon was re-administered. Three days later, body temperature returned to normal. On 25th hospital days, culture of blood and catheter tip was positive for C. parapsilosis. On 27th hospital days, sudden onset high fever, pnumonic infiltration, confusion, hypotension, oliguria and azotemia developed. On 34th hospital day, sudden onset ventricular fibillation developed. On 35th hospital day, the patients died. We report a case of candida fungemia in acute pancreatitis and hepatitis associated with typhoid fever.

Frequency and Associated Factors of Lung Involvement in Early Rheumatoid Arthritis / 대한류마티스학회지

OBJECTIVE: To determine the frequency and associated factors of physiologic abnormalities indicative of lung disease in early rheumatoid arthritis (RA). METHODS: Thirty-six early RA patients(mean age 43+/-12 years, 30 females, disease durations less than 12 months, mean duration 5+/-3 months), who had not been treated with disease modifying antirheumatic drugs (DMARDs), were studied. Clinical, laboratoy and radiologic variables such as age, sex, smoking history, past lung disease history, drug medication history, rheumatoid factor positivity, erythrocyte sedimentation rate (ESR), CRP and chest radiography, were undertaken. Pulmonary function tests (PFTs) were performed in all patients and results for PFTs were expressed as percentage of predicted values for each individual adjusted for age, sex, and height. Lung disease was defined as one or more of the followings should be present, 1) forced vital capacity (FVC) <80% for predicted, 2) diffusing capacity of carbon monoxide (DLCO) <80% for predicted, 3) forced expiratory flow from 25% and 75% of vital capacity (FEF 25-75%) <80% for predicted. Statistical comparisons were made using Student? t test or chi-square test as appropriate. RESULTS: All patients had normal chest radiography. Rheumatoid factor was positive in 21 patients (58%), smokers were 5 patients (14%), ESR and CRP were increased in 16 (44%) and 17 patients (47%). Ten patients (28%) had lung disease and included FVC <80% in 4, DLCO <80% in 4 and FEF 25-75% <80% in 6 patients. There was no significant predictor of lung disease. CONCLUSION: The frequency of lung disease in early RA by PFTs was 28% and there was no significant predictor of lung disease.

A Case of Early Aplastic Anemia due to Low Dose Methotrexate in Rheumatoid Arthritis / 대한류마티스학회지

Low dose methotrexate (MTX) is widely used for treatment of rheumatoid arthritis (RA) due to prompt clinical response, relatively lack of serious side effects, tolerability and simplicity of medication. However, several serious adverse effects have been reported with the use of MTX. The prevalence of hematologic toxicity, including leukopenia, thrombocytopenia, megaloblastic anemia, and pancytopenia, is estimated to be 3% in MTX-treated RA patients. Pancytopenia, which occurs unpredictably, is one of the most serious adverse effects and the prevalence is estimated to be 1.4% and fatal pancytopenia reported to occur in 17% of these patients. Old age, impaired renal function, concurrent infection, hypoalbuminemia, increased mean corpuscular volume of red blood cell, concomitant medication such as trimethoprim-sulfamethoxazole and nonsteroidal antiinflammatory drug, are the risk factors of MTX induced pancytopenia. We experienced a case of fatal MTX induced early aplastic anemia in RA patients who medicated 3 times MTX (7.5mg/weekly, 22.5mg of cumulative dose) refractory to treatment with steroid pulse, recombinant human granulocyte macrophage colony stimulating factor (rhGM-CSF) and immunoglobulin.

A case of hemolytic uremic syndrome complicating acute pancreatitis / 대한내과학회지

The hemolytic uremic syndrome (HUS) is characterized by microangiopathic hemolytic anemia, thrombocytopenia and acute renal failure. Microvascular thromboses in HUS may involve intestine, pancreas, skeletal muscle, and heart. Microinfarcts in the pancreas may cause acute pancreatitis and rarely insulin-dependent diabetes mellitus. Acute pancreatitis is a relatively common complication of HUS in children, but rare (2%) in adults. We have experienced a 43 year-old woman with HUS complicating acute pancreatitis. She presented with hemolytic anemia, thrombocytopenia and acute renal failure. During hemodialysis, she complained of left side abdominal and back pain. On laboratory study, levels of serum amylase and lipase were elavated. The size and shape of pancreas was normal on abdominal ultrasonography and computed tomography. We present this case with a review of literature.

A case of Polymyositis with Involvement of Liver / 대한류마티스학회지

Polymyositis is non-hereditary, autoimmune rheumatic disease characterized by progressive symmetrical proximal muscle weakness due to chronic inflammation of skeletal muscles. Its definite causes are unknown, genetic and environmental factors including some viral infections such as hepatitis C virus were associated with development of autoimmunity. Clinical symptoms are symmetrical proximal muscle weakness, arthritis, interstitial lung disease, heart failure and gastrointestinal disturbance. We experienced a case of polymyositis which involved liver and developed chronic hepatitis confirmed by liver biopsy.