Erythema Nodosum after Vaccination against Coronavirus Disease 2019 / 대한피부과학회지

Erythema nodosum (EN) is the most common form of panniculitis and may be triggered by a variety of stimuli, including infections, drugs, pregnancy, sarcoidosis, inflammatory bowel disease, and malignancies. Rare cases of vaccination-related EN have been reported, but none due to the coronavirus disease 2019 (COVID-19) vaccine of Pfizer have been documented. We report a case of EN associated with the Pfizer vaccine. A 43-year-old woman presented with acute-onset painful nodular lesions that appeared bilaterally on the extensor surface of the lower legs. These lesions appeared 5 days after the first dose of Pfizer vaccination. The patient reported no recent infectious history other than fever for 3 days after vaccination. Skin biopsy revealed inflammation extending into the subcutaneous fat with a septal distribution. It is important for physicians to be aware of the side effects of the COVID-19 vaccine because more people are bound to be vaccinated.

Monoclonal Gammopathy-Associated Scleredema Adultorum of Buschke in a Patient with Diabetes Mellitus Successfully Treated with Intravenous Immunoglobulin and Narrow-Band Ultraviolet B Phototherapy: A Case Report

no abstract available.

Clinical Features and Prognostic Factors of Stevens-Johnson Syndrome and Toxic Epidermal Necrolysis: A Multicenter Retrospective Study of Data from 88 Patients / 대한피부과학회지

Background@#Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN) are potentially fatal acute hypersensitivity reactions that involve the skin and mucous membranes. Because they are relatively rare diseases, it is difficult to obtain well-organized epidemiological data. The clinicodemographic characteristics, culprit drugs, and factors related to disease prognosis may vary. @*Objective@#To identify the characteristics of SJS/TEN by investigating patient clinicopathological characteristics, laboratory findings, suspected drugs, and mortality through a retrospective study using medical record data. @*Methods@#The clinical records of patients diagnosed with SJS/TEN between February 2009 and February 2019 at three medical institutions of Soonchunhyang University were retrospectively reviewed. Data pertaining to sex, age, history, suspected drugs, latent period, laboratory findings, and mortality were collected, and their correlations were analyzed. @*Results@#We identified SJS/TEN in 88 patients. Among the probable causative agents, antibiotics were the most common (29 cases, 33.0%), followed by nonsteroidal anti-inflammatory drugs (NSAIDs) in 20 cases (22.7%). The period between drug administration and symptom onset varied with the causative agent. Patients who died had high SCORTEN scores. In addition, hypertension, diabetes, renal failure, and cardiac disease had a statistically significant association with high SCORTEN. @*Conclusion@#Antibiotics, NSAIDs, antiepileptics and allopurinol were the most commonly implicated drugs in our retrospective study. There was a significant correlation between comorbidities. Because SJS/TEN is a life-threatening condition, early recognition of the suspected drug are important. The results of this study may provide insights that aid in the early diagnosis and prediction of disease outcomes of SJS/TEN in the Korean population.

Clinical Features and Prognostic Factors of Stevens-Johnson Syndrome and Toxic Epidermal Necrolysis: A Multicenter Retrospective Study of Data from 88 Patients / 대한피부과학회지

Background@#Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN) are potentially fatal acute hypersensitivity reactions that involve the skin and mucous membranes. Because they are relatively rare diseases, it is difficult to obtain well-organized epidemiological data. The clinicodemographic characteristics, culprit drugs, and factors related to disease prognosis may vary. @*Objective@#To identify the characteristics of SJS/TEN by investigating patient clinicopathological characteristics, laboratory findings, suspected drugs, and mortality through a retrospective study using medical record data. @*Methods@#The clinical records of patients diagnosed with SJS/TEN between February 2009 and February 2019 at three medical institutions of Soonchunhyang University were retrospectively reviewed. Data pertaining to sex, age, history, suspected drugs, latent period, laboratory findings, and mortality were collected, and their correlations were analyzed. @*Results@#We identified SJS/TEN in 88 patients. Among the probable causative agents, antibiotics were the most common (29 cases, 33.0%), followed by nonsteroidal anti-inflammatory drugs (NSAIDs) in 20 cases (22.7%). The period between drug administration and symptom onset varied with the causative agent. Patients who died had high SCORTEN scores. In addition, hypertension, diabetes, renal failure, and cardiac disease had a statistically significant association with high SCORTEN. @*Conclusion@#Antibiotics, NSAIDs, antiepileptics and allopurinol were the most commonly implicated drugs in our retrospective study. There was a significant correlation between comorbidities. Because SJS/TEN is a life-threatening condition, early recognition of the suspected drug are important. The results of this study may provide insights that aid in the early diagnosis and prediction of disease outcomes of SJS/TEN in the Korean population.

The Two Cases of Multifocal Fixed Drug Eruption Caused by Diclofenac / 대한피부과학회지

Fixed drug eruption (FDE) is a drug-induced disorder that may appear as patches or bullae. It recurs at the same sites as those involved in exposure to the same drug (causative drug). We encountered two cases of generalized FDE, and both patients had a history of diclofenac exposure before the onset of skin lesions. In the first case, an 82-year-old female patient presented with multiple erythematous patches on the trunk and lower extremities. In the second case, a 71-year-old male patient developed multiple bullae on violaceous patches on the trunk and extremities. The findings of histopathologic examinations were indicative of the diagnosis of FDEs. Although diclofenac is commonly used as a non-steroidal inflammatory drug, diclofenac-induced generalized FDE occurs rarely and has not been reported in Korea. With reuse of causative drugs, the size and number of lesions tend to increase. Therefore, early diagnosis of FDE is important, and avoidance of repeated exposure to drugs should be educated.

A Case of Tattoo-acquired Verruca Plana / 대한피부과학회지

No abstract available.

Increased inflammatory mediator in exhaled breath condensate from asthmatic children

PURPOSE: There has recently been increasing interest in the use of exhaled breath condensate (EBC) as a simple noninvasive means for understanding the physiology of asthma. The aim of this study was to evaluate the levels of leukotriene B4 (LTB4) and eosinophil cationic protein (ECP) in the EBC of asthmatic children. METHODS: We measured LTB4 and ECP levels in EBC from children aged 6-14 years, including healthy children (n=25) and asthmatic children (n=25). We also measured serum LTB4 and serum ECP. Pulmonary function tests and methacholine challenge tests were performed on all subjects. RESULTS: Exhaled LTB4 levels were increased significantly in patients with asthma compared to normal subjects (7.1+/-3.7 pg/mL vs. 2.2+/-1.7 pg/mL, P<0.05). Serum LTB4 levels were not significantly different in patients with asthma compared to normal subjects (674.7+/-484.1 pg/mL vs. 487.1+/-272.0 pg/mL, P=0.156,) and no significant correlations were found between exhaled and serum LTB4 concentrations in children with asthma (r=0.052, P=0.758). Exhaled ECP levels were not significantly different in patients with asthma compared to normal subjects (P=0.419). Serum ECP levels were significantly increased in patients with asthma compared to normal subjects (44.37+/-32.14 microg/L vs. 16.40+/-13.23 microg/L, P=0.001). CONCLUSION: We found significantly elevated LTB4 levels in the EBC of asthmatic children. Our results suggest that EBC may be one of the supportive tools to measure airway inflammation in children with asthma.

Palonosetron has superior prophylactic antiemetic efficacy compared with ondansetron or ramosetron in high-risk patients undergoing laparoscopic surgery: a prospective, randomized, double-blinded study / 대한마취과학회지

BACKGROUND: Postoperative nausea and vomiting (PONV) continues to be a major problem, because PONV is associated with delayed recovery and prolonged hospital stay. Although the PONV guidelines recommended the use of 5-hydroxy-tryptamine (5-HT3) receptor antagonists as the first-line prophylactic agents in patients categorized as high-risk, there are few studies comparing the efficacies of ondansetron, ramosetron, and palonosetron. The aim of present study was to compare the prophylactic antiemetic efficacies of three 5HT3 receptor antagonists in high-risk patients after laparoscopic surgery. METHODS: In this prospective, randomized, double-blinded trial, 109 female nonsmokers scheduled for elective laparoscopic surgery were randomized to receive intravenous 4 mg ondansetron (n = 35), 0.3 mg ramosetron (n = 38), or 75 microg palonosetron (n = 36) before anesthesia. Fentanyl-based intravenous patient-controlled analgesia was administered for 48 h after surgery. Primary antiemetic efficacy variables were the incidence and severity of nausea, the frequency of emetic episodes during the first 48 h after surgery, and the need to use a rescue antiemetic medication. RESULTS: The overall incidence of nausea/retching/vomiting was lower in the palonosetron (22.2%/11.1%/5.6%) than in the ondansetron (77.1%/48.6%/28.6%) and ramosetron (60.5%/28.9%/18.4%) groups. The rescue antiemetic therapy was required less frequently in the palonosetron group than the other groups (P < 0.001). Kaplan-Meier analysis showed that the order of prophylactic efficacy in delaying the interval to use of a rescue emetic was palonosetron, ramosetron, and ondansetron. CONCLUSIONS: Single-dose palonosetron is the prophylactic antiemetics of choice in high-risk patients undergoing laparoscopic surgery.

Sedation and general anesthesia outside of the operating room

BACKGROUND: The aim of this study is to evaluate the status and adverse events of anesthesiologist-administered sedation and general anesthesia, outside of the operating room. METHODS: Patients undergoing sedation and general anesthesia, outside of the operating room, were retrospectively reviewed, during the study period from March to October of 2011. The patient's characteristics, primary diagnosis for the procedure, procedures performed outside of the operating room, adverse events associated with sedation and anesthesia, sedatives/anesthetic agents, and anesthetic time, were all assessed. RESULTS: A total of 429 patient's submitted data on 44 sedation/401 general anesthesia were encountered, during the study period. The range of age varied from 2 months to 83 yrs. Most common primary diagnosis for the procedure, during sedation or general anesthesia, was vascular or neurologic problem, respectively. The most frequently used sedatives or analgesics were propofol alone, during sedation (45%) and propofol with remifentanil, during general anesthesia (60%), respectively. Adverse events occurred in 32%, during sedation and 29%, during general anesthesia. Bradycardia occurred in 16% of sedation and hypotension occurred in 15% of general anesthesia. CONCLUSIONS: Our data suggest that the sedation/general anesthesia for procedures, outside of the operating room, have been performed in a complex situation, various location, and wide age groups. Adequate monitoring, sufficient anesthesia support, including skilled staff and emergency equipments, and appropriate drug for each procedure are needed for the patient's safety.

A Case of Gluten Allergy in a 4-Year-Old Boy With Recurrent Urticaria / 소아알레르기및호흡기학회지

Wheat is the most widely cultivated grain and an important source of food and dietary protein. Wheat proteins are classified based on extraction in different solvents, which are albumin, globulin, prolamin (gliadin) and glutenin. The term 'gluten' contains approximately equal amounts of gliadin and glutenin and is the major determinant of the properties of wheat flour conferring cohesiveness and viscoelasticity that allows its dough to be processed into many kinds of food. Gluten is known to be responsible for triggering celiac disease and wheat allergy. Wheat allergy is primarily an IgE-mediated response. Clinical manifestations of wheat allergy are similar to those of other food allergies, with symptoms on the skin, gut and respiratory tract. Recent studies have shown that IgE to gliadin can be an indicator for risk of severe immediate reaction-like anaphylaxis and wheat-dependent, exercise-induced anaphylaxis (WDEIA). However, current in vitro test reagents for the diagnosis of wheat allergy mainly contain water-soluble wheat protein and a small amount of gluten, so there are some limitations to diagnose gluten allergy. Furthermore, there is no acceptable method to measure gluten in food products for preparing effective gluten-free diet. To overcome these limitations and to improve quality of life of wheat allergy sufferers, more work is needed. We report a case of a 4-year-old boy with gluten allergy who presented with urticaria after ingestion kneaded wheat flour with a brief review of the literature.

Effects of Epidural Fentanyl on Speed and Quality of Block for Emergency Cesarean Section in Extending Continuous Epidural Labor Analgesia Using Ropivacaine and Fentanyl

We performed a prospective, randomized, and double-blind study comparing the top-up effects of 2% lidocaine/100 microgram fentanyl/epinephrine (n=31) and 2% lidocaine/saline/epinephrine (n=30) when extending an epidural labor analgesia using low-dose ropivacaine and fentanyl. Survival analysis for the sensory blocks to the T4 level showed no statistically significant differences in onset time to T4 between the 2 groups. Onset times (min) to T4-sensory blocks for cold and pinprick were not different between the two groups. However, median maximum sensory level in the lidocaine-fentanyl group (T1 for cold and T2 for pinprick) was significantly higher than that in the lidocaine-saline group (T3 and T4, respectively). The lidocaine-fentanyl group exhibited less visceral pain (6.5% vs. 36.7%), less supplementation of lidocaine (6.5% vs. 43.3%), and less nausea (6.5% vs. 26.7%) compared with the lidocaine-saline group during the intraoperative period. It is concluded that adding fentanyl to 2% lidocaine does not speed up the onset of the block when the onset is tested with cold or sharp pinprick but improves the quality of analgesia with fewer side effects in emergency top-up for cesarean section.

Bladder puncture associated with caudal block in a pediatric patient undergoing day surgery: A case report / 대한마취과학회지

Although single-shot caudal blockade is known as a relatively safe procedure, it is not always without complications. We present a case of accidental bladder puncture that was identified with fluoroscopy by chance after single-shot caudal blockade in a 17-months-old, 12 kg boy who underwent inguinal hernioplasty.

Estimating lumbar epidural space depth in infants and children of Korea / 대한마취과학회지

BACKGROUND: Lumbar epidural block is now a popular technique for anesthesia and post operative analgesia. It may be helpful for prevention of complication during this procedure to know the depth from the skin to the lumbar epidural space before the procedure. This study was undertaken to evaluate the depth from the skin to the lumbar epidural space and to determine any potential relationship between a patient's data (age, weight, and height) and the measured depth in Korean children. METHODS: We investigated the electronic records of 662 Korean children who were received urologic surgeries with epidural catheterization for postoperative analgesia. The patients' gender, age, weight, height and epidural depth were recorded and analyzed with multiple linear regression test using SPSS 13.0 (SPSS Co., Ilinois, USA). RESULTS: The patient's age and weight were significantly correlated to the skin-epidural space depth in Korean children. Body weight was more significant variable than age on the epidural depth. The empirical formula derived from the results was as follow; epidural depth (mm) = 9 + 0.5 x body weight (kg) - 0.2 x age (months). CONCLUSIONS: We suggest that the depth of skin-lumbar epidural space can be estimated with the empirical formula based on body weight and age.

Penile Erection during Transurethral Surgery : Case report and review of the literature

Imbalance between sympathetic and parasympathetic nervous systems is generally considered an underlying mechanism for intraoperative erection, although local stimulation before complete sensory blockade can contribute to the problem. With the onset of erection under regional anesthesia during an operative procedure, general inhalational anesthesia must be quickly initiated to enhance venous drainage of the engorged corpora cavernosa before prolonged venous stasis. Combination therapy including ketamine, glycopyrrolate, terbutaline, and alpha-adrenergics may be available, however, the benefit-risk ratio should be considered especially in the elderly patients with cardiovascular diseases. We present a case of intraoperative erection in an elderly patient, which was resolved by applying inhalational anesthesia with remifentanil after confirmation ineffectiveness of intravenous glycopyrrolate and ketamine. We also review and discuss the treatment strategies.

A Comparisons of Remifentanil versus Alfentanil-based Total Intravenous Anesthesia (TIVA) for Oocyte Retrieval / 대한마취과학회지

BACKGROUND: This prospective, randomized, double-blind study was carried out to compare the effect of remifentanil with that of alfentanil, as a part of total intravenous anesthesia (TIVA) on the hemodynamic profile, recovery characteristics, visual analogue scale (VAS) for postoperative pain, and serum cortisol changes in the patients undergoing oocyte retrieval. METHODS: The patients were assigned to receive either propofol-remifentanil (n = 31) or propofol-alfentanil (n = 30). When the target propofol concentration (3.0microgram/ml) was reached, the study drugs were administered over a 60 s period with the loading dose (either remifentanil 1microgram/kg or alfentanil 10microgram/kg) and were maintained with a continuous infusion (either remifentanil 0.08microgram/kg/min or alfentanil 0.4microgram/kg/min). The propofol requirements, blood pressure, pulse rate, serum cortisol, VAS scores for pain, recovery profile and postoperative side effect were recorded in both the operating and recovery rooms. RESULTS: There were significant differences in the VAS score for postoperative pain 30 minutes after oocyte retrieval between the two groups. CONCLUSIONS: The propofol-remifentanil and propofol-alfe ntanil techniques are suitable for oocyte retrieval but the propofol-remifentanil technique requires additional analgesics for postoperative pain due to the rapid offset of remifentanil.

Posterior Reversible Encephalopathy Syndrome after Cesarean Section under Spinal Anesthesia: A case report / 대한마취과학회지

A posterior reversible encephalopathy syndrome (PRES) is characterized as headache, altered mental function, seizure, and visual disturbances resulted from vasogenic edema in the brain. A 29-year-old normotensive parturient developed a postural headache two days after the cesarean section under spinal anesthesia. The headache was initially misdiagnosed as a postdural puncture headache (PDPH). The patient experienced generalized seizures four days after delivery. Her blood pressure increased to 170/100 mmHg with mild proteinuria. She developed homonymous hemianopsia two days after the seizures. MRI revealed high signal intensity areas in the posterior temporal, frontal, occipital and parietal white matter. Presuming a diagnosis of PRES, the patient was treated with magnesium sulfate, sodium valproate, and carbohydrate solutions. She was discharged without headache or neurologic deficit on postoperative day 13. When patients present a headache with focal neurological deficits or visual disturbances, the anesthesiologist must consider the possibility of PRES and aggressively treat based on the clinical presentation.

Effects of Metoclopramide and Ranitidine on Preoperative Gastric Contents in Day-Case Surgery

This prospective, randomized, double-blinded study was performed to evaluate the effects of intravenous metoclopramide and ranitidine on preoperative gastric contents in outpatients receiving intravenous anesthesia for laparoscopic gynecologic surgery. Fifteen minutes before the induction of anesthesia, the Z-M group (n=20) received 50mg ranitidine and 10mg metoclopramide intravenously and the control group (n=20) received the same volume of normal saline. Before the surgery, a 14-F multiorifice nasogastric tube was inserted to aspirate the gastric contents of patients under sedation with propofol and midazolam. The mean pH values of the gastric fluid were 2.7+/-2.0 (SD) [median 1.6 (range: 1.2-7.2)] in the control group, and 6.1+/-1.9 [median 6.8 (range 1.4-7.8)] in the Z-M group. The mean aspirated volumes (mL) were 15.3+/-10.4 (SD) [median 11.0 (range: 5.0-44.0)] in the control group, and 6.9+/-10.0 (SD) [median 4.5 (range: 0-38.0)] in the Z-M group. There were significantly more high-risk (gastric fluid volumes > 25mL and pH < 2.5) patients in the control group (4/20, 20%) than in the Z-M group (1/20, 5%). In conclusion, intravenous prophylactic ranitidine and metoclopramide may be an easy and useful method to decrease the volume while increasing the pH of gastric contents, and therefore may reduce the number of patients at risk for aspiration pneumonitis in ambulatory laparoscopic procedures who receive an anesthesia.

Effects of Metoclopramide and Ranitidine on Preoperative Gastric Contents in Day-Case Surgery

This prospective, randomized, double-blinded study was performed to evaluate the effects of intravenous metoclopramide and ranitidine on preoperative gastric contents in outpatients receiving intravenous anesthesia for laparoscopic gynecologic surgery. Fifteen minutes before the induction of anesthesia, the Z-M group (n=20) received 50mg ranitidine and 10mg metoclopramide intravenously and the control group (n=20) received the same volume of normal saline. Before the surgery, a 14-F multiorifice nasogastric tube was inserted to aspirate the gastric contents of patients under sedation with propofol and midazolam. The mean pH values of the gastric fluid were 2.7+/-2.0 (SD) [median 1.6 (range: 1.2-7.2)] in the control group, and 6.1+/-1.9 [median 6.8 (range 1.4-7.8)] in the Z-M group. The mean aspirated volumes (mL) were 15.3+/-10.4 (SD) [median 11.0 (range: 5.0-44.0)] in the control group, and 6.9+/-10.0 (SD) [median 4.5 (range: 0-38.0)] in the Z-M group. There were significantly more high-risk (gastric fluid volumes > 25mL and pH < 2.5) patients in the control group (4/20, 20%) than in the Z-M group (1/20, 5%). In conclusion, intravenous prophylactic ranitidine and metoclopramide may be an easy and useful method to decrease the volume while increasing the pH of gastric contents, and therefore may reduce the number of patients at risk for aspiration pneumonitis in ambulatory laparoscopic procedures who receive an anesthesia.

The Effects of Volume Preloading on Spinal Anesthesia for Elective Caesarean Section

BACKGROUND: We have compared the protective effect of 1,000 ml preload on prevention of hypotension with 200 ml preload of crystalloid solution, administered during the 10 min before spinal anesthesia in 30 healthy women undergoing elective caesarean section. METHODS: Systolic blood pressure (SAP) and heart rate (HR) were measured as index of hypotension due to vasodilaton. Ephedrine IV bolus was treated as a decrease in systolic blood pressure to less than 70% of baseline value or to less than 90 mmHg. Apgar score, umbilical artery and vein blood gas analysis were also checked as parameters of fetal well-being. RESULTS: There was no difference in changes in maternal HR, SAP during spinal anesthesia between the two groups. There was no significant difference in ephedrine requirements between the two groups. There was no effect on the clinical condition of the newborn in each group, as assessed by Apgar scores and umbilical cord blood gas analysis. CONCLUSIONS: These results suggest that volume preloading is not essential to prevent spinal-induced hypotension at caesarean section.

Comparison of Preoperative Gastric Contents between Gestational Diabetic and Normal Pregnant Women Undergoing Elective Cesarean Delivery / 대한마취과학회지

BACKGROUND: Delayed gastric emptying occurs frequently in diabetic patients. The aim of this study was to investigate preoperative gastric acidity and volume in parturients with gestational diabetes mellitus (GDM) undergoing elective cesarean delivery. METHODS: Twenty-five full term gravid women with GDM (GDM group) and another twenty-five without any complication (control group) were recruited. Before the anesthesia, a 14-F multiorifice nasogastric tube was inserted and the gastric contents were directly aspirated. RESULTS: There were no differences in the aspirated gastric pH and volumes between the groups (2.6 pH with 29.9 ml in the control group vs. 2.5 pH with 29.8 ml in the GDM group). The numbers of patients at-risk for aspiration, pH 25 ml in the two groups were similar (9/25, 36% in the GDM group, 7/25, 28% in the control group). CONCLUSIONS: Diabetes does not increase the risk of aspiration pneumonitis compared to the normal pregnant women in elective cesarean delivery.