A case of pancytopenia secondary to low-dose pulse methotrexate therapy in a patient with rheumatoid arthritis and renal insufficiency

Most reports on serious MTX toxicity have focused on hepatic abnormalities, while other effects, including hematologic reactions, have not been emphasized. We experienced a case of pancytopenia secondary to MTX therapy in a patient with RA and renal insufficiency. A 67-year-old woman with a 12-year history of active seropositive RA that was a response to non-steroidal anti-inflammatory drugs, hydroxychloroquinine and intra-articular steroid injections, had been followed up and was diagnosed as early chronic renal failure in October, 1993. Recently, because of significant morning stiffness and polyarthralgia, the decision was made to institute MTX treatment. This was begun as a single oral dose of 5mg/week. After 2 doses, the patient was admitted to the hospital with general weakness. Laboratory tests showed a hemoglobin level of 7.9 g/dl, WBC count 1800/mm3 and platelet count of 64000/mm3. The serum creatinine level was 6.1 mEq/dl and the BUN level was 82 mEq/dl. Liver function test results were normal, but the serum albumin level was 2.7 g/dl. The patient subsequently developed fever and blood transfusions, granulocyte colony stimulating factor (G-CSF) and intravenous prophylactic antibiotic therapy were required. Her condition was improved. In summary, Low-dose MTX-related adverse hematologic side effects, including fatal pancytopenia, are rare but are a cause of increasing concern in patients with RA and renal insufficiency. Close monitoring of associated risk factors, particularly impaired renal function, should be mandatory for all patients who are receiving MTX therapy.

Human adjuvant disease manifesting as SLE / 대한내과학회지

Human adjuvant disease means the autoimmune disease or autoimmune disease like syndrome developed after plastic surgery using foreign body implantation. After first report of HAD by Miyoshi at 1964, a number of cases have been reported especially from Japan. Silicone has been known as biologically inert material, but a couple of side reaction and experimental data argue against such conventional idea. It is impossible to identify the exact role of implanted substance in the occurrence of autoimmune disease, but there are a few indirect evidences for adjuvant effect of silicone. The spectrum of HAD are as follows: unclassifiable connective disease like syndrome, rheumatoid arthritis, SLE, polymyositis, adult Still's disease, ITP, Hashimoto's thyroiditis, etc. We experienced two cases of HAD manifesting as SLE who had been injected with silicone fluid with for augmentation mammoplasty and report this with a review of the literature.

Analysis of Hypokalemia in Emergency Patients / 대한신장학회잡지

OBJECTIVES: Hypokalemia is one of the most common electrolyte disorders encountered in clinical medicine. It is important electrolyte disorder because it is account for neuromuscular, cardiovascular and renal disturbance. But there are few studies to evaluate the incidence and cause of hypokalemia in emergency patients. Present study was performed to evaluate the incidence and cause of hypokalemia and coincidental changes of other electrolyte and chemical parameters of blood and urine. METHODS: Hypokalemia was defined as a serum potassium concentration less than 3.5mEq/L. A total 80 medical patient without renal failure were prospectively studied for 62 days. Electrolytes and chemical parameters of the blood and urine were determined at emergency room. RESULTS: 1) Of medical inpatients through emergency room, hypokalemia was detected in high frequency(32%) and mild degree(mean; 3.1+/-0.1mEq/L). 2) The most common cause of hypokalemia was diuretics(23%), other causes were vomiting, SIADH, diarrhea, alkalemia, and unidentified cause(each; 15.4%). 3) Compared to the normokalemic group, the hypokalemic group showed significant decrease in urinary anion gap(P=0.003). 4) There was no significant difference of spot urine potassium concentrations between renal and extrarenal origin of hypokalemia. CONCLUSION: The hypokalemia in emergency patients was detected in high frequency and mild degree. Urine anion gap was significantly decreased in hypokalemic group than normokalemic group. Spot urine potassium concentration was less effective in differentiation of renal and extrarenal origin of hypokalemia.

A Case of Recovery from Suspended Animation caused by Puffer fish Poisoning: a case report

Tetrodotoxin is a neurotoxin produced by about 90 species of puffer fish and causes paralysis of central nervous system and peripheral nerves by blocking the movement of all monovalent cations. Ingestion of tetrodotoxin produces clinical manifestations such as paresthesias(within 10-45 min), vomiting, lightheadedness, salivation, muscle twitching, dysphagia, difficulty in speaking, convulsion and death that expressed by cardiopulmonary arrest with loss of brain stem reflex sometimes. Tetrodotoxin prevents or delays ischemia induced neuronal death by way of following 3 mechanisms. Firstly, it reduces the energy demand of the brain tissues. Secondly, it delays or even prevents anoxic depolarization. Finally, it diminishes ischemia induced cell swelling and cerebral edema. We report a case of puffer fish poisoning which presented with cardiopulmonary arrest and loss of brain stem reflex, but completely recovered by aggressive cardiopulmonary resuscitation.

Initial Transient Neurologic Recovery Followed by Delayed Deterioration of Osmotic Demyelination Syndrome: A Case Report / 대한신장학회잡지

In literatures, most of the studies of severe hyponatremia during or following its treatment has been concentrated with special references to the rate of correction and its neurologic outcomes. But, there is relatively few ones analyzing the diverse clinical manifestations of neurologic symptorns or complications during the course of treating severe hyponatremia. We experienced a catastrophic course related to hyponatremia in a 51 year woman with severe rheumatoid arthritis, who underwent knee joint replacement, and this case revealed the initial transient neurologic recovery for 3 days by the initial rapid correction of hyponatremia, then followed by delayed deterioration of osmotic demyelination syndrome leading to locked-in syndrome. Reported cases with similar clinical course (biphasic course) in the world lituratures were reviewed with special interests in the initial maximum rate of correction of hyponatremia and radiologic findings. This review suggests that clinicians treating the patients with severe symptomatic hyponatremia should be aware of the possibility of delayed neurologic sequelae despite the recovery of neurologic status as well as the degree of hyponatremia in the early treatment course of hyponatremia.

Clinical Analysis of Severe Hyponatremic Patients with Neurologic Symptoms / 대한신장학회잡지

OBJECTIVE: Severe hyponatremia is rare but constitute a true medical emergency since it has deleterious effects on the central nervous system. The etiology and clinical presentation of severe hyponatremia are diverse and nonspecific, furthermore, the optimal therapeutic approach is debatable at the present time. Therefore, the purpose of this study is to analyze the clinical manifestations of severe hyponatremic patients and to assess the outcomes with special reference to the rate of its correction. METHODS: This retrospective study analyzed the clinical course of 27 consecutive patients(pts) at a single medical center who presented with neurologic hyponatremic symptoms as well as a serum sodium (Na) concentration less than 125mEq/L. RESULTS: Of 27 hyponatremic patients, male to female ratio was almost equal, 13 to 14, and mean age was 67.1 years. The most common cause of hyponatremia was SIADH(11 pts, 40.7%), followed by hypovolemia(11 pts, 37.1%), and edema(4 pts, 14.8%). Hyponatremic neurologic symptoms included lethargy(33.3%), confusion with drowsy mentality (33.3%), dizziness(18.6%), and semicoma(7.4%), respectively. The rate of increase to a serum Na concentration to 125mEq/L during correction of hyponatremic averaged 0.56+/-0.49mEq/L/hr while the maximum increase in serum Na concentration during any period of the hospital course, mostly initial phase, averaged 0.69+/-0.63mEq/L/hr in all 27 pts, of whom 18 pts(66.7%) was less than 0.5mEq/L/hr, 3 pts from 0.5 to 1.0mEq/L/hr(11.1%), and 6 pts more than 1.0mEq/L/hr(22.2%). All 27 pts but one recovered from neurologic symptoms due to hyponatremia without neurologic sequale. Extrapontine myelinolysis with locked in condition was developed during the course of treating hyponatremia in a pts, of whom serum Na concentration before treatment was the lowest(92mEq/L) with the rate of correction to 125mEq/L by 1.26mEq/L/hr and the initial rate of correction within the first 6 hour by 3.17mEq/L/hr. No one died of hyponatremia itself during the course of its treatment but 3 deaths of 27 pts were attributed to the pts' severe underlying diseases. CONCLUSION: Surprisingly, these data revealed the relatively benign course of severe symptomatic hyponatremia. However, in assessing the outcome of severe symptomatic hyponatremia, the initial degree of hyponatremia as well as the rate of correction during its treatment, particularly the initial rate of correction within the first 6 hour, would be considered.

A Case of Bleeding Duodenal Varices in a Patient with Idiopathic Portal Hypertension / 대한소화기내시경학회지

Bleeding duodenal varices are a rare complication in patients with portal hypertension. Cirrhosis followed by portal vein obstruction and splenic vein obstruction are the most common causes. Although the prognosis of bleeding duodenal varices is usually poor, an awareness of its characteristic presentation may enable diagnostic and therapeutic proce- dures to be performed rapidly with an increased likelihood of a reaching successful out- come. In this study, we report a case of bleeding duodenal varices in a 23-year-old woman with idiopathic portal hypertension who was also suffering with recurrent melena. Panendoscopy identified prominant tortuous varices with central erosion in the 3rd portion of the duodenum and no esophageal and gastric varices. The varices were successfully treated by distal splenorenal shunt.