A Case of Urosepsis Caused by Aerococcus viridans / 대한내과학회지

Aerococcus viridans is a rare pathogen in humans, with only six cases of A. viridans urinary tract infections reported worldwide. Nosocomial urinary tract infections with bacteremia caused by A. viridians are even rarer, with no prior reports of urosepsis caused by A. viridans occurring in the Republic of Korea. Here we report a case of urosepsis caused by A. viridans in a 79 year-old female nursing home resident. The patient was admitted to the hospital presenting a fever of 39degrees C, chills, and oliguria for two days prior to admission. Urine culture yielded a robust growth of 105 CFU/mL of A. viridians, with blood culture positive for the same organism. Following diagnosis, the patient was treated with ciprofloxacin intravenously for 2 weeks, resulting in clearance of the infection and a full recovery from urosepsis. Although A. viridans is rarely associated with human infections, this case shows that, under the right conditions, it can be responsible for severe infections like urosepsis.

Serum Retinol-Binding Protein-4 Levels Are Increased in HIV-Infected Subjects with Metabolic Syndrome Receiving Highly Active Antiretroviral Therapy

Metabolic syndrome is an important long term complication in chronic asymptomatic HIV-infected subjects under highly active antiretroviral therapy (HAART), because it can contribute to morbidity and mortality via cardiovascular disease (CVD). Therefore, a predictive marker for early detection of metabolic syndrome may be necessary to prevent CVD in HIV-infected subjects. Retinol-binding protein-4 (RBP-4) has been shown to be associated with metabolic syndrome in various non-HIV-infected populations. We performed a cross-sectional study to evaluate whether serum RBP-4 levels are correlated with metabolic syndrome in HIV-infected subjects receiving HAART. In total, 98 HIV-infected Koreans who had been receiving HAART for at least 6 months were prospectively enrolled. Metabolic syndrome was diagnosed according to the Adult Treatment Panel III criteria, and serum RBP-4 concentrations were measured using human RBP-4 sandwich enzyme-linked immunosorbent assay. Serum RBP-4 levels were significantly higher in HIV-infected subjects receiving HAART with metabolic syndrome (n=33, 33.9+/-7.7 microg/mL) than in those without it (n=65, 29.9+/-7.2 microg/mL) (p=0.012). In multivariate linear regression analysis, the number of components of metabolic syndrome presented and waist circumference were independently, significantly correlated with RBP-4 (p=0.018 and 0.030, respectively). In conclusion, we revealed a strong correlation between RBP-4 and the number of components of metabolic syndrome in HIV-infected subjects receiving HAART.

ERRATUM: Risk Factors and Prognosis for Persistent Candidemia without Catheter Colonization / 감염과화학요법

No abstract available.

Clinical Features of Re-Emerging Hepatitis A: An Analysis of Patients Hospitalized during an Urban Epidemic in Korea

From April 2008 to November 2008, many cases of hepatitis A were reported in Seoul and Gyeonggi Province in Korea. Furthermore, the rate of severe or fulminant hepatitis have significantly increased during the latest epidemic (13.4% vs. 5.2%, p=0.044). Therefore, widespread use of vaccine is warranted to reduce the burden of hepatitis A in Korea.

Risk Factors and Prognosis for Persistent Candidemia without Catheter Colonization / 감염과화학요법

BACKGROUND: Candidemia is one of the most common causes of nosocomial bloodstream infection, and increases the morbidity and mortality rate of seriously ill patients. We evaluated the risk factors and outcomes associated with persistent candidemia without catheter colonization (non-catheter related candidemia) and compared them with those of non-persistent candidemia. MATERIALS AND METHODS: A retrospective case-control study was performed to identify risk factors for, and outcomes of, persistent candidemia. All adults who experienced candidemia in a university-affiliated hospital in Korea between January 2005 and December 2009 were included. Patients with catheter colonization were excluded. Persistent candidemia was defined as the occurrence of candidemia in a patient receiving at least 3 days of systemic antifungal agents prior to the second positive blood culture. RESULTS: Of 605 adult patients with candidemia, 104 (17.2%) patients had persistent candidemia and 23 (3.8%) patients were free of catheter colonization. There were no statistically significant differences in baseline characteristics between patients with persistent and non-persistent candidemia. In univariate analysis, less use of metronidazole, glycopeptide, fluoroquinolone, and aminoglycoside, and presence of Candida parapsilosis were significantly associated with persistent candidemia. In multivariate analysis, less use of metronidazole was an independent factor associated with persistent candidemia. The candidemia related mortality was insignificantly (P=0.094) higher in persistent candidemia than non-persistent candidemia. CONCLUSIONS: Persistent candidemia can occur without catheterization. Patterns of antibiotic use could be associated with the occurrence of persistent candidemia, and prognosis of persistent candidemia seems to be worse than non-persistent candidemia. Further studies for persistent candidemia should be performed.

Cryptococcal Meningitis : 12 Years Experience in a Single Tertiary Health Care Center / 감염과화학요법

BACKGROUND: Cryptococcal infections are frequent in human immunodeficiency virus (HIV)-infected patients. This infection may occur in other immunocompromised patients, and the diagnosis is often delayed in these cases. There are a few reports on cryptococcal meningitis in non-HIV-infected patients in Korea. We reviewed the clinical features and efficacy of antifungal therapy in 33 patients who were treated at a single tertiary health care center of Korea. MATERIALS AND METHODS: The medical records of 33 consecutive patients who were admitted to one tertiary hospital for cryptococcal meningitis between 1995 and 2008 were reviewed retrospectively. Cryptococcal meningitis was confirmed by positive cerebral spinal fluid (CSF) cultures or compatible clinical features plus a positive cryptococcal antigen test of CSF. RESULTS: Of the 33 patients analyzed, 30 cases were non-HIV patients. The outcomes were complete cure in 23 cases, relapse after initial treatment in four cases, and death due to treatment failure in six cases. The main initial manifestations were headache (84.8%), fever (54.5%), and seizure (33.3%). Factors significantly associated with unfavorable outcomes, including mortality and relapse, were afebrile condition, mental change, hearing impairment, initial high opening pressure of CSF (>250 mmH2O), and low initial absolute neutrophil count. On multivariate analysis, afebrile condition was an independent predictor of an unfavorable outcome (odds ratio 17.3; 95% confidence interval 1.0-28.3; P=0.045). CONCLUSIONS: It is necessary to observe closely cryptococcal meningitis patients without fever on admission.

A case of systemic lupus erythematosus associated with Kikuchi's disease / 대한내과학회지

Initially described in young Japanese women, Kikuchi's disease predominantly produces histiocytic necrotizing lymphadenitis of the cervical lymph nodes along with fever; it always follows a benign course with excellent outcomes. Kikuchi's disease is rarely associated with systemic lupus erythematosus (SLE). However, the microscopic features of Kikuchi's disease can be similar to lupus lymphadenitis. Patients with Kikuchi's disease should be assessed for SLE and have long-term follow-up evaluations for the development of SLE. We present a 21-year-old woman with tender multiple cervical lymphadenopathy and the clinical manifestations of SLE.

A Case of Non-islet Cell Tumor Hypoglycemia / 대한내분비학회지

Mesenchymal tumors including hemangiopericytomas, hepatocellular tumors, adrenal carcinomas, and a variety of other large tumors have been reported to produce excessive amounts of insulin-like growth factor (IGF) type II precursor, which binds weakly to insulin receptors and strongly to IGF-I receptors, leading to insulin like actions. In addition to increased IGF-II production, IGF-II bioavailability is increased due to complex alterations in circulating binding proteins. The authors of this article diagnosed non-islet cell tumor hypoglycemia from an 81-year-old male patient suffering from repetitive fasting hypoglycemia while he has not received any treatment for pulmonary hemangiopericytoma diagnosed in the past. Moreover, this topic is getting reported as the authors have experienced a significant improvement of catamnesis by a treatment with glucocorticoid.

A Case of Primary Aldosteronism with Rhabdomyolysis / 대한신장학회잡지

Primary aldosteronism is a clinical syndrome of muscle weakness, hypertension and hypokalemia due to excess secretion of mineralocorticoid by the adrenal gland. In primary adlosteronism, muscle weakness is often caused by excess secretion of aldosterone, however, to our knowledge there have been no case reports rhabdomyolysis due to severe hypokalemia in domestic cases. A fifty-eight year old female who presented with myalgia was admitted into the hospital. Initial laboratory values demonstrate marked hypokalemia with elevated creatinine kinase and LDH. Also, her urine myoglobin was positive and plasma renin activity level was decreased and serum aldosterone level was increased. Owing to a high clinical suspicion of primary aldosteronism, an abdominal CT scan was performed revealing 1.6 cm sized mass in the right adrenal gland. After surgery, her blood pressure was normalized and serum potassium level was maintained to normal range without potassium replacement therapy. She is now in outpatient care under close follow-up. We report a case of a patient with paralysis of both lower extremities and myalgia, who later found to have primary aldosteronism with rhabdomyolysis due to severe hypokalemia.

Role of Thigh Muscle in the Carotid artery Intima-Media Thickness and Insulin resistance / 대한내분비학회지

BACKGROUND: There have been recent reports that the fat distribution within skeletal muscle and the amount of muscle mass are associated with insulin resistance and the development of type 2 diabetes mellitus (T2DM). This study evaluated the impacts of visceral fat and thigh muscle from patients with T2DM and healthy subjects on atherosclerosis and insulin resistance. METHODS: Forty-two patients with newly-developed T2DM and 11 healthy subjects were selected for the study. The diabetic patients were subdivided into two groups, those under 40 years of age, as the young T2DM (n=21) group, and 40 years-old or greater, as the old T2DM (n=21) group. CT scans were obtained for all patients at the L4-L5 level and at the mid-portion between the greater trochanter and upper margin patella. The carotid intima-media thickness (IMT) was also measured using high resolution B-mode ultrasonography. RESULTS: The mean visceral fat area (VFA) in the old T2DM group was 169.4+/-13.2cm2, which was significantly greater than that found in the healthy subjects (67.9+/-7.92cm2, P<0.001) and young T2DM group (127.1+/-10.4cm2, P<0.05). The mean visceral fat to normal density muscle area ratio (VMNR) in the old T2DM group was 1.50+/-0.19, which was greater than in the healthy subjects (0.46+/-0.52, P<0.001) and young T2DM group (1.01+/-0.10, P<0.05). The total thigh muscle areas in the young and old T2DM groups were smaller than that in the healthy subjects, but without statistical significance. VMNR showed a positive correlation with the IMT and HOMA-IR. However, the total thigh muscle area was negatively correlated with the IMT. The normal density muscle area also showed significant negative correlations with the IMT and HOMA-IR. In a multiple regression analysis, age and VMNR were the most important independent risk factors of an increased carotid IMT. CONCLUSION: This study showed that the role of thigh muscle, as well as that of visceral fat, played a very important role in the occurrence of atherosclerosis. VMNR was found to be an especially important independent factor for an increased carotid IMT.

A Case of Rhabdomyolysis Caused by Group A beta-hemolytic Streptococcal Tonsillopharyngitis / 대한신장학회잡지

Bywaters and beall first reported rhabdomyolysis during World War II; the pigmented casts were found in renal tubules of 4 patients who died of acute renal failure after crushing injury. Since then, several cases of rhabdomyolysis with or without acute renal failure have been reported. The causes such as surgical injuries, excessive exercise, and drug abuse have been suggested as possible etiologies of rhabdomyolysis. Rhabdomyolysis is a clinical syndrome as a result of releasing of myocyte components from the injured striated muscles into blood stream. Clinical manifestations have ranged from asymptomatic elevation of creatinine kinase to acute renal failure which is a life threatening medical emergency. The most common cause of rhabdomyolysis is traumatic muscular injury. The others include alcohol abuse, metabolic disorder, drug, toxins, carbon monoxide poisoning, burn, vascular occlusion, excessive exercise, and bacterial or viral infections and sepsis. Among these, rhabdomyolysis caused by Group A beta-hemolytic streptococcus is very rare. However, rhabdomyolysis due to pharyngitis has not been reported. We report a case of rhabdomyolysis associated with Group A beta-hemolytic streptococcus.