A Case of Bleeding from a Periampullary Duodenal Varix that Developed after Biliary Metal Stent Placement in a Patient with Pancreatic Cancer / 대한소화기내시경학회지

Duodenal varices bleed less commonly than gastro-esophageal varices in patients with portal hypertension. However, if there is no stigmata of recent esophageal or gastric variceal bleeding, clinicians should suspect the presence of an extra gastro-esophageal site of variceal bleeding. Duodenal variceal bleeding can be difficult to diagnose and treat. Therefore, the bleeding may be life threatening in most cases and has a poor prognosis. We experienced a case of variceal bleeding that developed in a patient with far advanced pancreatic cancer after placement of a self- expanding metal stent into a strictured bile duct via the peroral and transpapillary route. The patient had a duodenal varix near the major papilla and the bleeding was treated with an injection of Histoacryl(R). We thought the bleeding of the periampullary varix resulted from injury due to exposure to the free end of the alloy wires in the distal portion of the inserted biliary metal stent.

A Case of Primary Jejunal Adenocarcinoma Diagnosed by Enteroscopy using Pediatric Colonoscope / 대한소화기학회지

A 39-year-old man presented with dizziness and melena for 2 months. Abdominal CT scan showed constrictive wall thickening with enhancement and proximal loop dilatation of the jejunum. On endoscopic examination, there was large amount of bile stained fluid in duodenum. Enteroscopy using pediatric colonoscope demonstrated an encircling mass with obstruction approximately 20 cm distal to the ligament of Treitz. Endoscopic jejunal biopsy showed moderately differentiated adenocarcinoma. Small intestinal adenocarcinoma is uncommonly encountered in clinical practice. Because small intestine is relatively inaccessible via routine endoscopy, diagnosis of small intestinal neoplasm is often delayed for several months after the onset of symptoms. Most of the patients are diagnosed in advanced stage. Therefore, when a small bowel neoplasm is suspected, enteroscopy is the most useful study. If enteroscope is not available, enteroscopy using pediatric colonoscope may permit earlier preoperative diagnosis. We report a case of primary jejunal adenocarcinoma diagnosed by endoscopic biopsy using pediatric colonoscope.

A Case of Concomitant Disseminated Gonococcal Infection with Acute Viral Hepatitis C

Gonorrhea is endemic in developing countries. Frequent sexual contacts are common among travellers to endemic countries and the risk of sexually transmitted disease as gonorrhea is believed to be high. Disseminated gonococcal infection (DGI) results from blood dissemination of Neisseria gonorrhoeae from the primary mucosal infection and is a common cause of infective arthritis in sexually active adults in the USA. The usual manifestations of DGI are dermatitis, tenosynovitis, and septic arthritis. We experienced a case of DGI concomitant with acute viral hepatitis C, probably acquired by sexual contacts in Philippines. A 40-year-old man took a trip to Philippines and stayed for a week. During his stay in Philippines, a hemorrhagic bulla and several pustules developed on his extrimities. Subsequently he suffered from high fever and arthralgia of several joints, including both knee joints. Neisseria gonorrhoeae was identified by culture of an aspirate from the right knee joint and he was managed with ceftriaxone for 3 weeks under the diagnosis of DGI and gonococcal arthritis. During the follow-up at the outpatient clinic, alanine aminotransferase and aspartate aminotransferase levels began to rise and an anti-HCV antibody became positive. Because HCV viral loads were surging up from 56,703 copies/mL to 538,292 copies/mL during the next 4 weeks, interferon-alpha 2b was administered for 6 months with resultant normal liver function tests and undetectable HCV viral loads.

A Case of Concomitant Disseminated Gonococcal Infection with Acute Viral Hepatitis C

Gonorrhea is endemic in developing countries. Frequent sexual contacts are common among travellers to endemic countries and the risk of sexually transmitted disease as gonorrhea is believed to be high. Disseminated gonococcal infection (DGI) results from blood dissemination of Neisseria gonorrhoeae from the primary mucosal infection and is a common cause of infective arthritis in sexually active adults in the USA. The usual manifestations of DGI are dermatitis, tenosynovitis, and septic arthritis. We experienced a case of DGI concomitant with acute viral hepatitis C, probably acquired by sexual contacts in Philippines. A 40-year-old man took a trip to Philippines and stayed for a week. During his stay in Philippines, a hemorrhagic bulla and several pustules developed on his extrimities. Subsequently he suffered from high fever and arthralgia of several joints, including both knee joints. Neisseria gonorrhoeae was identified by culture of an aspirate from the right knee joint and he was managed with ceftriaxone for 3 weeks under the diagnosis of DGI and gonococcal arthritis. During the follow-up at the outpatient clinic, alanine aminotransferase and aspartate aminotransferase levels began to rise and an anti-HCV antibody became positive. Because HCV viral loads were surging up from 56,703 copies/mL to 538,292 copies/mL during the next 4 weeks, interferon-alpha 2b was administered for 6 months with resultant normal liver function tests and undetectable HCV viral loads.

A Case of Acute Pachymeningitis Misdiagnosed as Subdural Hematoma in a Patient with Polyarteritis Nodosa / 대한류마티스학회지

The pathymeningitis is a very rare neurologic manifestation of PAN. We report a case of pathymeningitis misdiagnosed as subdural hematoma by brain CT in a patient with PAN. A 45-year old man who diagnosed as PAN through arteriography and skin biopsy in the ischemic finger 6 months ago. He complained of sudden headache, nausea, and diplopia 3 days before admission. In emergency room, noncontrast brain CT findings suggested small amount of subdural hematoma. But subsequent MRI findings revealed pachymeningitis of bilateral paratentoria and falx. He was treated with high-dose steroid and cyclophosphamide pulse therapy. Thereafter, his symptoms were gradually resolved. As far as we know, this is the first report of a case of pachymeningitis complicating PAN in Korea.

Ultrasound Imaging Supplements the Plain Radiography in the Evaluation of the Knee Osteoarthritis / 대한류마티스학회지

OBJECTIVE: Ultrasonography (USG) of joints has a unique position for the diagnosis of joint diseases. Bone surface, cartilage, periarticular soft tissue and their pathologic changes can be assessed by USG. This study was aimed to compare the radiographic and ultrasonographic findings in osteoarthritis (OA) of the knee joint and to evaluate the usefulness of each modality to evaluate the disease early and determine the severity of the arthritis. METHODS: Fifty osteoarthritis patients classified by the American College of Rheumatology (ACR) clinical criteria from December 2002 to April 2003 were included in the study. Routine radiography (standing anteroposterior, lateral, skyline view) and systemic USG examination of both knee were performed. We compared the incidence of the radiographic and ultrasonographic abnormality related to the pathologic change of the knee OA and suggesting the severity of the OA which would help to decide the therapeutic modality. RESULTS: In patient with knee OA, plain radiography showed abnormal findings in 37/50 (74%) patients, but USG showed at least five abnormal findings in all 50 patients. The abnormal findings detected only by plain radiography were subchondral sclerosis and subchondral cyst (14% and 4% each). But, the thinning of cartilage (94%), Baker's cyst (94%), cartilage degeneration (54%), meniscal protrusion (44%), meniscal tear (34%), meniscal cyst (32%), and the pannus (22%) were detected only by USG. Among the findings shared by both method, joint space narrowing was detected better by plain radiography than USG, but fluid accumulation, spur, meniscal calcification and osteochondroma were detected more frequently by USG. CONCLUSION: USG is more sensitive to find the pathologic changes related to the knee OA and to diagnose OA than the plain radiography. But each of the plain radiography and USG have their own unique value for the evaluation of OA in the knee. So the USG supplements the plain radiography in the examination of the knee OA.

A Case of Primary Localized Tracheobronchial Amyloidosis / 결핵

Primary pulmonary amyloidosis is a rare condition that can be classified into the tracheobronchial, diffuse alveolar septal, and nodular parenchymal type. Tracheobronchial amyloidosis is characterized by deposition of fib rilar proteins in the tracheobronchial tree, and it can be subdivided into diffuse and focal varieties. In this report, a case of diffuse tracheobronchial amyloidosis confirmed by flexible fiberoptic bronchoscopic biopsy is presented. The patient was a 43-year old male with a chief complaint of cough and sputum for 20 days and dyspnea for one day. The chest CT scan showed diffusely thickened walls of both the main and lobar bronchi with calcification. The bronchoscopic findings showed nodular lesions of the trachea, a diffuse bronchial stenosis of both the main bronchi and a pinpoint narrowing of the left upper and right middle lobar bronchus. The biopsy showed submucosal deposits of homogenous eosinophilic amyloid materials and an apple-green birefringence under polarizing microscopy following the Congo-red stain.