Antiviral Efficacy of Lamivudine/Adefovir Combination Therapy in Chronic Hepatitis B Patients with Resistance to Lamivudine and Adefovir Consecutively / 대한소화기학회지

BACKGROUND/AIMS: The aim of this study was to elucidate the antiviral efficacy of lamivudine (LMV)-adefovir (ADV) combination therapy in chronic hepatitis B patients who showed resistance to LMV and ADV consecutively. METHODS: A retrospective review was performed in eighteen patients with chronic hepatitis B who developed virologic breakthroughs during LMV-ADV sequential mono-therapy and treated with LMV-ADV combination therapy. RESULTS: The median duration of follow up was 17 months (range, 6-27) after the start of LMV-ADV combination therapy. Mean HBV DNA level in log10 IU/mL was 6.08+/-0.95, 4.05+/-1.66, 3.17+/-1.58, 3.18+/-2.16, and 2.35+/-1.52 at 0, 3, 6, 12, and 24 months, respectively. Sixteen patients (88.9%) showed HBV DNA reduction below detection limit (<20,000 IU/mL). HBeAg seroconversion was observed in one patient (7.1%) after 8 months of combination therapy. Virologic breakthrough occurred in only one patient after 21 months of combination therapy. Viral rebound occurred in two patients at 12 months and 14 months of combination therapy. Normalization of serum ALT was achieved in twelve patients (66.7%). Primary non-response was observed in two cases (11.1%). CONCLUSIONS: LMV-ADV combination treatment was effective in 88.9% of patients with resistance to LMV and ADV in a short-term follow up. It may be applied as a bridge therapy until another effective antiviral regimen becomes available.

The effect of low dose corticosteroid therapy on viral reactivation in patients with chronic hepatitis B virus infection / 대한내과학회지

BACKGROUND/AIMS: We investigated the effect of low dose corticosteroid therapy on HBV reactivation in patients with chronic HBV infection. METHODS: From August 1998 to March 2007, the HBsAg-positive patients who received oral or intravenous corticosteroid therapy for more than 1 week at Samsung Medical Center were included in this retrospective study. We included those patients who received anticancer chemotherapy or organ transplantation, or concurrent antiviral therapy or other immunosuppressive agents. HBV reactivation was defined as a 10-fold increase in the HBV DNA levels compared with baseline. RESULTS: A total of 16 patients were included. They were 45.4+/-16.7 years of age, and the male:female ratio was 14:2. Their combined diseases included bronchial asthma, allergic urticaria, allergic rhinitis, etc. The corticosteroid doses were converted to prednisolone equivalent doses and these varied from 2.5 mg to 50 mg per day. Eleven patients used less than 20 mg of prednisolone per day. The mean medication duration was 60.1 days (range: 7-364 days). Among the patients, only one patient showed HBV reactivation. This ankylosing spondylitis patient was a 31-year old man who took prednisolone 5 mg/day for 364 days. He displayed HBeAg-positivity before corticosteroid treatment. There was no aggravation of the levels of ALT, albumin, bilirubin, and PT between the pre-and post-medication in this patient. CONCLUSIONS: The short term use of low dose corticosteroid is not likely to be related with HBV reactivation in those patients with chronic HBV infection, yet long term use may lead to viral reactivation. Further large scaled, prospective studies on this subject are needed.

A Case of Poststreptococcal Reactive Arthritis

Poststreptococcal reactive arthritis (PSRA) is associated with recent streptococcal infections. However, PSRA is distinct from acute rheumatic fever by its clinical manifestations: non-migrating arthritis, erythema nodosum or erythema multiforme, and transient elevation of serum transaminases. We experienced a 33-year-old man who presented with fever, arthritis of both knees and ankles, and erythema nodosums on extensor surfaces of lower legs which developed 6 days after the onset of pharyngitis symptoms. Blood and urine cultures were negative. Throat culture was negative for group A beta-hemolytic streptococcus. The ASO titers increased up to 2080 IU/mL in sequential monitoring. The result of bone scan was compatible to arthritis of both knees and ankles. There were no signs or symptom of carditis. He showed clinical improvement with anti-inflammatory drugs (naproxen 1,000 mg/day and prednisolone 7.5 mg/d). PSRA should be included in the differential diagnosis of patients presenting with arthritis combined with fever.

A Case of Poststreptococcal Reactive Arthritis

Poststreptococcal reactive arthritis (PSRA) is associated with recent streptococcal infections. However, PSRA is distinct from acute rheumatic fever by its clinical manifestations: non-migrating arthritis, erythema nodosum or erythema multiforme, and transient elevation of serum transaminases. We experienced a 33-year-old man who presented with fever, arthritis of both knees and ankles, and erythema nodosums on extensor surfaces of lower legs which developed 6 days after the onset of pharyngitis symptoms. Blood and urine cultures were negative. Throat culture was negative for group A beta-hemolytic streptococcus. The ASO titers increased up to 2080 IU/mL in sequential monitoring. The result of bone scan was compatible to arthritis of both knees and ankles. There were no signs or symptom of carditis. He showed clinical improvement with anti-inflammatory drugs (naproxen 1,000 mg/day and prednisolone 7.5 mg/d). PSRA should be included in the differential diagnosis of patients presenting with arthritis combined with fever.

A Case of Hypersensitivity Pneumonitis Caused by Methotrexate / 결핵

BACKGROUND: Methotrexate (MTX) has been used to treat a wide range of malignant and benign diseases including osteosarcoma, advanced stage non-Hodgkin's lymphoma, psoriasis, severe rheumatoid arthritis, sarcoidosis, and Wegener's granulomatosis. MTX-induced lung injury occurs in up to 10% of treated patients. Although both acute and chronic presentations have been described, typical manifestation of MTX-induced lung injury is subacute with symptoms usually developing within several months after starting therapy. Nonspecific interstitial pneumonia (NSIP) is the most common histopathologic manifestation of MTX-induced lung disease, while bronchiolitis obliterans organizing pneumonia (BOOP) and diffuse alveolar damage (DAD) are less common. Granuloma formation is reported in 34.7%. In Korea, Two reports of MTX pneumonitis have been published. The one presented with NSIP and the other with DAD. We recently experienced a case of MTX pneumonitis with presentation of hypersensitivity pneumonitis.

Significance of Endoscopy in the Investigation of Iron Deficiency Anemia / 대한소화기내시경학회지

BACKGROUND/AIMS: There is no consensus for the role of endoscopy in the etiologic investigation of iron deficiency anemia (IDA) in Korea. We carried out a retrospective study to evaluate the role of esophagogastroduodenoscopy (EGD) and colonoscopy for their etiologic diagnosis in IDA. METHODS: Between January 1998 and September 2003, 129 patients (male:female=19:110, mean age=43.6) had been grew EGD and colonoscopy for exam for the investigation of IDA at Kangbuk Samsung Hospital and Samsung Medical Center Medical records were retrospectively reviewed: RESULTS: Significant findings were found in 8.5% (11 cases: grade B reflux esophagitis by L.A. classification (1), angiodysplasia (1), severe erosive gastritis (2), and gastric ulcer (2) and duodenal ulcer (5), while 70% (89 cases) showed some abnormality in EGD examination. Significant findings were seen in 11% (14 cases: polyps >1 cm (2), angiodysplasia (1), bleeding hemorrhoids (5), inflammatory bowel disease (4) and colon cancer (2)), among 36% (46 cases) of patients with some abnormality in colonoscopy. CONCLUSIONS: Gastrointestinal lesions were frequently found in patients with IDA and significant proportion of them could be the source of blood loss. Therefore, EGD and colonoscopy should be included in the evaluation of IDA in Korea.

A case of chronic diarrhea caused by duodenocolic fistula / 대한내과학회지

The four basic mechanisms that cause chronic diarrhea are osmotic, secretory and exudative factors, and abnormal intestinal transit. A gastrointestinal fistula cause chronic diarrhea by abnormal intestinal transit, and it must be included differential diagnosis for unknown cause of chronic diarrhea. Duodenocolic fistula is an uncommon cause of chronic diarrhea. The most common cause of duodenocolic fistula is a colon cancer. Benign duodenocolic fistula is a rare disease, which the most common cause is a duodenal ulcer. Patients usually complain of diarrhea, weight loss. Physical examinations are nonspecific. Barium enema is the most useful diagnostic procedure. Prognosis is good if surgery is undertaken at an early stage. We present a case of a 66-years old man in whom a duodenocolic fistula maybe caused by recurrent microperforation of duodenal ulcer. He complained of chronic diarrhea and weight loss. He had an operation on his fistula, and remained well.

A Case of Spontaneous Renal Artery Dissection Secondary to Fibromuscular Dysplasia and Treatment by Renal Arterial Stenting / 대한신장학회잡지

Isolated spontaneous renal artery dissection (SRAD) associated with fibromuscular dysplasia (FMD) is a rare condition that can result in renal infarction. Treatment and long-term management of patients with this condition is controversial. We report the case of a patient with SRAD secondary to FMD who was treated by renal arterial stenting. A previous healthy 50-year-old white male presented to the emergency department with acute right flank pain. Blood pressure was 150/90 mmHg and serum creatinine was 1.6 mg/dL. A CT scan of the abdomen showed multifocal right renal infarction. The patient was started on anticoagulant regimen of heparin. Renal angiography showed the dissection of right renal artery and stenosis of mid-segment of right main renal artery and intrarenal branches. We decided to perform percutaneous balloon angioplasty and stenting for the purpose of dilating the stenotic renal artery, preventing recurrence of the disease and controlling hypertension and elevated creatinine. A dissected intimal flap was closed successfully by renal artery stenting and stenotic renal artery was dilated by stenting and balloon angioplasty. Five days after the procedure, he was discharged with warfarin. Three months later, he had normal renal function and blood pressure without antihypertensive medication was mildly elevated at 145/104 mmHg. Conclusively, stent implantation to renal artery dissection can be effective, reliable and feasible and can be an alternative to surgical treatment.