Clinical Characteristics of Endobronchial Tuberculosis that Develops in Patients over 70 Years of Age / 결핵및호흡기질환

BACKGROUND: The possibility of developing pulmonary tuberculosis usually increases with increasing age. Therefore, the incidence of endobronchial tuberculosis in older people may increase. We evaluated the clinical characteristics in patients with endobronchial tuberculosis above the age of 70 years. METHODS: We enrolled 74 patients (12 males and 62 females; mean age 64.6+/-16.2 years) that were diagnosed with endobronchial tuberculosis from March 2003 to July 2006 at Gyeongsang University Hospital. We retrospectively evaluated the clinical characteristics of endobronchial tuberculosis for patients 70 years or older (older group) and for patients below the age of 70 years (younger group). RESULTS: The number of patients in the older group was 41 (55%). Cough was the most common symptom in the two groups of patients and dyspnea on exertion was more common in the older group of patients than in the younger group of patients (31.7% vs. 12.1%). The actively caesating type of disease was more common in the younger group of patients than in the older group of patients (66.7% vs. 39%). The edematous type of disease was more common in the older group of patients than in the younger group of patients (53.7% vs. 27.2%) (p<0.05). Tracheal and main bronchial involvement of lesions were more common for the younger group of patients than for the older group of patients (30.3% vs. 9.7%) (p<0.05). CONCLUSION: Endobronchial tuberculosis was commonly observed in patients older than 70 years and this group of patients had some clinical characteristics that were different from the younger group of patients.

Relationship between Change of RBC Shape and Multi-organ Failure in Sepsis / 대한구급학회지

BACKGROUND: Microcirculatory derangement in sepsis plays a crucial role in the impairment of tissue oxygenation that can lead to multi-organ failure and death. The change of RBC rheology in sepsis has been known to be important factors in microcirculatory derangement. Several studies have demonstrated that RBCs have decreased deformability in sepsis. We investigated the relationship between multi-organ failure and spherical index of RBC estimated by flow cytometer in critically ill patients with or without sepsis compared with the relationship in healthy volunteers. METHODS: Fourteen non-septic critically ill patients, 18 septic patients and 10 healthy volunteers were evaluated. We obtained peripheral venous blood from each patient and analyzed the change of RBC shape using flow cytometer (Becton Dickinson FACSCalibur) within 90 minute. The change of RBC shape was accessed with spherical index (M2/M1). A decrease in M2/M1 was correlated with the sphericity of the RBC and considered to have a lower capacity to alter their shape when placed in microcirculation. Multi-organ failure was accessed with sequential organ failure assessment (SOFA) score. RESULTS: The M2/M1 ratio of healthy volunteers, non-septic patients and septic patients were 2.25+/-0.08, 2.16+/-0.39 and 2.05+/-0.53, respectively. But, there was no significant difference between each group (p>0.05). And, there was no significant correlation between M2/M1 ratio of septic and non- septic patients and SOFA score (p>0.05, r2= -0.13). CONCLUSIONS: In our study, the spherical index of RBC was not associated with multi-organ failure in sepsis. But, further studies may be needed to evaluate the role of RBC rheology in sepsis.

Usefulness of Cardiac Troponin I as a Prognostic Marker in Non-cardiac Critically Ill Patients / 결핵및호흡기질환

BACKGROUND: Cardiac troponin I (cTnI) is a specific marker of myocardial injury. It is known that a higher level of cTnI is associated with a poor clinical outcome in patients with acute coronary syndrome. An elevation in cTnI is also observed in various noncardiac critical illnesses. This study evaluated whether cTnI is useful for predicting the prognosis in noncardiac critically ill patients. METHODS: From June 2003 to July 2004 at Gyeongsang National University Hospital, we enrolled 215 patients (male:142, female:73, mean age:63+/-15 years ) who were admitted for critical illness other than acute coronary syndrome at the medical intensive care unit(ICU). The severity score of critical illness (SAPS II and SOFA) was determined and serum cTnI level was measured within 24 hours after admission to the ICU. The mortality rate was compared between the cTnI-positive (> or =0.1microgram/L) and cTnI-negative (cTnI<0.1microgram/L) patients at the 10th and 30th day after admission to the ICU. The mean cTnI value was compared between the survivors and non-survivors at the 10th and 30th day after admission to the ICU in the cTnI-positive patients. The correlation between cTnI and the severity of the critical illness score (SAPS II and SOFA) was also analyzed in cTnI-positive patients. RESULTS: 1) The number of cTnI-negative and positive patients were 95(44%) and 120(56%), respectively. 2) The mortality rate at the 10th and 30th day after admission to the ICU was significantly higher in the cTnI-positive patients (29%, 41%) than in the cTnI-negative patients (12%, 21%)(p<0.01). 3) In the cTnI-positive patients, the mean value of the cTnI at the 10th and 30th day after admission to the ICU was significantly higher in the non-survivors (4.5 +/- 9.2 microgram/L, 3.5 +/- 7.9 microgram/L) than in the survivors( 1.8 +/- 3.6 microgram/L, 2.0 +/- 3.9 microgram/L) (p < 0.05). 4) In the cTnI-positive patients, the cTnI level was significantly correlated with the SAPS II score (r=0.24, p<0.001) and SOFA score (r=0.30, p<0.001). CONCLUSION: The cTnI may be a useful prognostic marker in noncardiac critically ill patients.

Usefulness of Troponin-I, Lactate, C-reactive protein as a Prognostic Markers in Critically Ill Non-cardiac Patients / 결핵및호흡기질환

BACKGROUND: The severity scoring system is useful for predicting the outcome of critically ill patients. However, the system is quite complicated and cost-ineffective. Simple serologic markers have been proposed to predict the outcome, which include troponin-I, lactate and C-reactive protein(CRP). The aim of this study was to evaluate the prognostic values of troponin-I, lactate and CRP in critically ill non-cardiac patients. METHODS: From September 2003 to June 2004, 139 patients(Age: 63.3+/-14.7, M:F=88:51), who were admitted to the MICU with non-cardiac critical illness at Gyeongsang National University Hospital, were enrolled in this study. This study evaluated the severity of the illness and the multi-organ failure score (Acute Physiologic and Chronic Health Evaluation II, Simplified Acute Physiologic Score II and Sequential Organ Failure Assessment) and measured the troponin-I, lactate and CRP within 24 hours after admission in the MICU. Each value in the survivors and non-survivors was compared at the 10th and 30th day after ICU admission. The mortality rate was compared at 10th and 30th day in normal and abnormal group. In addition, the correlations between each value and the severity score were assessed. RESULTS: There were significantly higher troponin-I and CRP levels, not lactate, in the non-survivors than in the survivors at 10th day(1.018+/-2.58ng/ml, 98.48+/-69.24mg/L vs. 4.208+/-10.23ng/ml, 137.69 +/-70.18 mg/L) (p<0.05). There were significantly higher troponin-I, lactate and CRP levels in the non-survivors than in the survivors on the 30th day (0.99+/-2.66ng/ml, 8.02+/-9.54ng/dl, 96.87+/-68.83mg/L vs. 3.36+/-8.74ng/ml, 15.42+/-20.57ng/dl, 131.28+/-71.23mg/L) (p<0.05). The mortality rate was significantly higher in the abnormal group of troponin-I, lactate and CRP than in the normal group of troponin-I, lactate and CRP at 10th day(28.1%, 31.6%, 18.9% vs. 11.0%, 15.8 %, 0%) and 30th day(38.6%, 47.4%, 25.8% vs. 15.9%, 21.7%, 14.3%) (p<0.05). Troponin-I and lactate were significantly correlated with the SAPS II score(r2=0.254, 0.365, p<0.05). CONCLUSION: Measuring the troponin-I, lactate and CRP levels upon admission may be useful for predicting the outcome of critically ill non-cardiac patients.

A Case of aspergillus tracheobronchitis in non-immunocompromise patient / 결핵

The aspergillus tracheobronchitis is distinctive manifestation of invasive aspergillosis, in which infection is limited completely or predominantly to the tracheobronchial tree. It accounts for about 7 to 10 percent of cases of invasive disease. Grossly, such disease may take the mucosal exudate and obstruct partially the airway lumen or completely the occlusive mucous/fungus plugs. Microscopically, the superficial portion of the airway wall is acutely inflamed and contain fungal hyphae. However, infection is often limited to the mucosa. We report a case of aspergillus tracheobrochits in a 54 year-old man who presented cough, progressive dyspnea with wheezing, and mucus plug. Bronchoscopy showed mucosal exudate and plug.Bronchoscopic biopsy showed aspergillus hyphae and inflammation in the mucosa. He was successfully treated with itraconazole.

A Case of Vancomycin-resistant E. faecium Peritonitis in Patient with Continuous Ambulatory Peritoneal Dialysis / 감염

Enterococcus is a normal flora of the gastrointestinal or genitourinary tract. With the increased use of vancomycin and third generation cephalosporins, vancomycin-resistant enterococci (VRE) have become one of the major nosocomial pathogens in USA and Europe since 1986. In Korea, patients with VRE infection or colonization were increasingly reported recently and VRE may become a serious nosocomial pathogen in the near future. So we report a case of vancomycin-resistant E. faecium peritonitis in a patient on continuous ambulatory peritoneal dialysis.

A Case of chronic necrotizing pulmonary aspergillosis with pulmonary artery aneurysm / 결핵

Pulmonary aspergillosis is classified as a saprophytic, allergic, and invasive disease. Chronic necrotizing pulmonary aspergillosis is categorized as an invasive pulmonary aspergillosis. Most invasive pulmonary aspergillosis have acute and toxic clinical features but chronic necrotizing pulmonary aspergillosis is characterized by a sub-acute infection, most commonly seen in patients with altered local defense system from preexisting pulmonary disease of in mild immunocompromised patients. Pulmonary artery aneurysm due to this infection is termed as a mycotic aneurysm, etiology of which are tuberculosis, syphilis, bacteria and fungus. We report a case chronic necrotizing pulmonary aspergillosis complicating pulmonary aneurysm is a 62 year-old man who was presented with cough, sputum, and fever. Chest radiographs showed a rapid, progressive cavitary lesion and pulmonary artery aneurysm. Angioinvastion of aspergillus was revealed by pathology after operative removal of left upper lobe containing the pulmonary artery aneurysm. He was treated with itraconazole.

A case of intraabdominal abscess cured by transrectal catheter drainage / 대한내과학회지

Intraabdominal abscess, resulting from primary intraperitoneal disease such as appendicitis, diverticulitis or as a complication of surgery, remains a serious problem with high mortality if not treated early and adequately. In the case of acute bowel perforation, surgery is the treatment of choice, but radiologically guided percutaneous drainage is very effective for the subacute and localized abscess within the peritoneal cavity. However, perirectal abscesses located deep within the pelvis are unapproachable percutaneously because of interposed structures such as the urinary bladder, loops of bowel. Transrectal drainage overcomes these limitations. We present here a case of perirectal abscess treated successfully and safe with transrectal catheter drainge.

Relationship Between Airway Inflammation Assessed by Induced Sputum and Airway Hyperresponsiveness in Asthmatic Patient / 결핵

BACKGROUND: Airway inflammation and hyperresponsiveness are recognized as major characteristics of bronchial asthma. Airway inflammation has usually been assessed by invasive methods, e.g. BAL or bronchial biopsy, but recent studies proposed induced sputum as another reliable and non- invasive tool to investigate airway inflammation in asthmatic patients. Thus, the relationship between airway inflammation assessed by induced sputum and airway hyperresponsiveness was investigated in asthmatic patient. METHOD: Airway responsiveness was determined by the concentration that caused a 20% decrease in FEV1(PC20) after inhaling incremental concentrations of methacholine. The numbers of inflammatory cells and the concentration of eosinophilic cationic protein(ECP) were assessed in induced sputum obtained by inhalation of hypertonic saline(3%). RESULT: We analyzed sputum induced in 15 stable asthmatic patients. 1. The differential cell count(%) of macrophages, neutrophils, eosinophils and lymphocytes in induced sputum were 39.1 +/- 27.0%, 29.6 +/- 21.0%, 28.8 +/- 18.8%, 1.3 +/- 3.1% respectively. 2. The mean value of baseline FEV1 (Predicted) and ECP were 76.3 +/- 30.3% and 1,101 +/- 833 micro gram/L respectively. The geometric mean value of PC20 was 0.56mg/mL. 3. The relationships between the sputum eosinophil and ECP in induced sputum, and between sputum eosinophil and degree of airway responsiveness(PC20) were found be significantly correlated (r=0.81, p<0.05 and r=-0.78, p<0.05, respectively). 4. Sputum neutrophils and PC20 were not correlated to each other (r=0.11, p=0.69) and a significant negative correlation was found between ECP and baseline FEV1(predicted) (r=-0.62, p<0.05). CONCLUSION: The results of this study suggest that an induced sputum via a inhalation of hypertonic saline is useful to determine a patient's status of airway inflammation, and airway inflammation is one of the major causal factors in the development of bronchial hyperresponsiveness in asthmatic patients.

Effect of Vitamin C on Airway Hyperresponsiveness in Heavy Smokers / 결핵

BACKGROUND: Vitamin C has been reported to have a role in the decrease of airway hyperresponsiveness in animal models. This data is based on some metabolic actions of vitamin C, such as promotion of histamine degradation, producing mote PGE2 than PGE2 alpha in cyclooxygenase pathway, decrease of smooth muscle contraction, and acting as reducing agent of oxidant. It has been also known that heavy smokers have lower blood levels of vitamin C than nonsmokers and this deficiency in heavy smokers have been explained by several mechanisms, such as increased oxidation by oxidants and free radicals, increased biosynthesis of catecholamine and serotorim released by nicotine, and inadequate dietary intake. In this study, We attempted to assess effect of vitamin C on bronchial hyperresponsiveness in heavy smokers who have bronchial hyerresponsiveness and role of vitamin C on bronchial hyperresponsiveness. METHOD: To assess acute effect of vitamin C on airway hyperresponsiveness, blood sample for vitamin C level and spirometry, methacholine challenge test were done in 17 smokers and 8 nonsmokers, and one hour after oral administration of vitamin C 3 g, blood sample for vitamin C level and spirometry, metliacholine challenge test were repeated. To assess chronic effect of vitamin C on airway hyperreeponsiveness after daily administration of vitamin C 1 g for one week in 17 smokers, blood sample for vitamin C level and spirometry, methacholirie challenge test were done. To assess role of vitamin C, after oral administration of vitamin C 3 g plus indomethacin 100 mg in 12 of 15 smokers who were reactive to methacholine challenge test, spirometry and methacholine challenge test were done and after oral intake of indomethacin 100 mg in 12 smokers who were reactive to methacholine challenge test, spirometry and metbachoine challenge test were repeated. RESULT: There were no significant differences in whole blood vitamin C levels between smokers(1.17+/-0.22mg/dL) and nonsinokers(1.14+/-0.19 mg/dL) (p>0.05). Fifteen of the 17 smokers(88.2%) were reactive to metbacholine chaflenge test amd 10 of the 15 smokers who were reactive to methacholine challenge test were less than 8 mg/dL in PC20FEV1, and 7 of the 8 nonsmokers(87.5%) were nonreactive to methacltoline challenge test There were significant decrease in bronchial responsiveness after oral administration of xitamin C 3 g in 13 of the 15 smokers who were reactive to methachoine challenge test. This significant decrease persisted with maintenance daily administration of 1 g for one week. PC20FEV1 were not correlated to vitamin C levels in smokers. After oral administration of indomethacin 100 mg, significant reduction of bronchial responsiveness that occured after oral administration of xdtamin C 3 g in smokers were attenuated. CONCLUISON: Although there were no significant differences in whole blood vitamin C levels between smokers and nonsmokers, heavy smokers have significant increase in bronchial responsiveness than nonsmokers. This bronchial hyperresponsiveness of heavy smokers can be attenuated by vitamin C supplement Disappearance of vitamin C effect by indcrnethaein supplement may suggest that vitamin C exert its effect via alteration of arachidonic acid metabolism.