Delayed Onset of Malignant Hyperthermia: A Case Report / 대한구급학회지

Malignant hyperthermia is a potentially fatal genetic and metabolic myopathy that presents with high fever, and muscle rigidity, and it often occurs after administering anesthetic medication. Most cases of malignant hyperthermia occur during anesthesia or surgery, but delayed malignant hyperthermia is very rare, and if it is detected late, it has a high mortality rate. A 39-year-old male with an acute subdural hematoma underwent decompressive craniectomy without any intraoperative medical problems, but a high fever above 40degrees C occurred after 8 hours and he was dead in spite of aggressive management after 48 hours postoperatively. We present here a case of delayed malignant hyperthermia along with a review of the related literature.

Expression of Plus- and Minus-strand Viral RNA in Coxsackievirus B3-Infected A/J Mice

In order to investigate the implication of viral replication in acute, subacute, and chronic infections of coxsackievirus B3 (CVB3), we examined the histopathological changes and plus- and minus-strand viral RNA dynamics in heart, pancreas, brain, and liver of CVB3-infected A/J mice. Mice were inoculated intraperitoneally with CVB3 and sacrificed on 1, 2, 3, 4, 7, 10, 14, 21, 30, 60, and 90 days post infection (p.i.). Plus- and minus-strand viral RNAs in the organs were quantitated and the organs were additionally evaluated histopathologically for inflammation. No inflammatory infiltrates were observed in the liver, brain, and heart. In contrast, massive lymphocyte infiltration and fat replacement were shown in the pancreas with loss of acinar cells. Both plus- and minus-strand viral RNA levels were detected by 21 days p.i. in heart, 90 days p.i. in pancreas, 4 days p.i. in liver, and 10 days p.i. in brain. The plus-strand RNA was found at least fifty fold higher than the minus-strand RNA by 4 days p.i. in heart and pancreas and by 3 days p.i. in liver. The plus- to minus-strand RNA ratio in brain was found less than 1:20. Our data indicate that viral replication was actively occurred in heart, pancreas, and liver during acute CVB3 infection, whereas viral replication was limited in brain. Furthermore, chronic persistent viral RNA was observed in pancreas. In conclusion, CVB3 at low dose of virus induces severe pancreatitis but marginal or no inflammatory changes in the heart, liver, and brain.

Reduction of Zygomatic Arch Fractures Via Postauricular Approach

Zygomatic arch fracture is one of the most commonly seen facial bone fractures and there have been many methods of reduction designed so far. However, for a simple fracture, the Gillies temporal approach is most commonly used because of the easy reducibility, and also because the depressed fracture can be approached without a facial incision. The Gillies temporal approach starts in the temporal area, between the temporalis muscle and deep temporal fascia. We have developed a new route which starts in the postauricular hair margin area and then reaches to the periosteum of the temporal bone. An elevator is then inserted to penetrate the periosteum and subperiosteal dissection is performed toward the zygomatic process of the temporal bone. At the origin of the zygomatic process, the route of dissection changes to the posterior aspect of the zygomatic arch using a curved palate elevator or the authors' modified Langenbeck elevator. This method of approach has been used in 6 cases of zygomatic arch fracture with good results and we report this method along with written reports.

Cases of Vaginoplsty Using Pudendal-thigh Flaps

We performed 3 cases of pudendal-thigh flaps in patients with congenital absence of the vagina from June, 1996 through February, 1999. Pudendal-thigh flaps are posterior labial artery axial flaps based on the terminal vessels of the internal pudendal artery. The flaps are raised bilaterally in the groin crease just lateral to the labia majora and are then transposed toward the midline and sutured together to form a neovagina. With adequate flap dissection, reliable blood supply is maintained. Thus, complications such as flap necrosis do not occur and early wound healing is possible. It is s relatively simple technique which can be completed with little blood loss. This method can be completed in one stage, and the prolonged use of stents of dilators is not necessary, since the reconstructed vagina is stable. The linear scars of the donor sites are well hidden in the groin crease and perineum. Normal function is maintained postoperatively without change in sensation. The authors report these methods with a review of the literature.

A Clinical Analysis of Primary Intracranial Germ Cell Tumors

Primary intracranial germ cell tumors(GCTs) are relatively rare brain tumors that show a diverse range of histologic features from benign to highly malignant conditions. To determine their clinical findings, pathology, treatment and outcome, we analyzed the medical records of 45 patients with primary intracranial GCTs treated at our hospital between June 1989 and December 1996. Thirty-two were males and 13 were females, and their ages ranged from three to 43 years. Fifteen cases were located in the pineal region and 13 in the suprasellar. The remaining locations were the basal ganglia in eight cases, both the pineal and suprasellar region in five, and others in four. In the pineal region, there was a male predominance(13:2), but in the suprasellar region, more cases(ten of 13) involved females. Of the 15 patients with tumors of the pineal region, increased intracranial pressure(IICP) was evident in 12 and six had Parinaud's syndrome. Of the 13 patients with tumors of suprasellar region, nine had diabetes insipidus; seven, visual deficit; and six, hypopituitarism. Germinoma was the most common histologic type. Other types of histology were two teratomas, three embryonal carcinomas, one endodermal sinus tumor, one choriocarcinoma, and five mixed GCTs. All patients except those with a teratoma underwent whole craniospinal irradiation. We performed gross total or subtotal removal in cases of non-germinomatous GCTs(NGGCTs) and mixed tumors, but biopsy or partial removal was preferred for the germinomas. Thirteen of 45 patients received adjuvant chemotherapy. All malignant NGGCT and mixed tumor patients were treated with adjuvant chemotherapy, as well as three of 33 germinoma patients. Three of five malignant NGGCT patients and two of five mixed tumor patients died of tumor progression. Two of 33 germinoma patients died not of disease progression but of other causes. Actuarial survival records showed that overall two-year and five-year survival rates were 89.9% and 71.9%, respectively. There were no statistically significant differences with regard to patient's age, sex, or tumor location. With regard to their histology and surgical extent, malignant NGGCTs and mixed tumors showed statistically significant differences. Five-year surival rates of germinoma and malignant NGGCT patients were 83.1% and 53.3%, respectively. We suppose that the appropriate combination of chemotherapy and surgery, with or without radiation therapy, remains to be defined, and that to determine the appropriate management protocol for malignant NGGCTs and mixed tumors, larger series of patients must be analyzed.

Clinical Analysis of Posterior C1-C2 Fusion for Atlantoaxial Instability

The authors analyzed the surgical results of posterior C1-C2 fusion in 18 cases of atlantoaxial instability. Posterior C1-C2 wiring with bone fusion(11 cases), C1-C2 transarticular screw fixation(6 cases), and occipitocervical fusion(1 case) have been performed for unstable odontoid process fractures(10 cases), transverse ligament injury(4 cases), os odontoideum(3 cases), rheumatoid C1-2 instability(1 case). Follow-up examination was performed in all patientts after a mean postoperativeduration of 39.9 months. Follow-up x-rays showed successful stabilization in 17 cases(94%). Postoperative neurological evaluation showed improvement in 16 cases(89%), stabilization in 2 cases(11%) and there was no major operative complication.