Effect and Course of Percutaneous Transhepatic Cholangioscopy in Intrahepatic Stone Related Complication after Liver Resection / 대한췌담도학회지

BACKGROUND/AIMS: Percutaneous transhepatic cholangioscopy (PTCS) is an effective treatment used for intrahepatic stone in patients who have undergone hepatectomy. There are few reports on natural course in these patients. Thus, we report the long-term results. METHODS: We conducted a retrospective study of 19 patients who underwent PTCS after hepatectomy at Samsung Medical Center between January 1998 and December 2014. We investigated patient characteristics and recurrence of biliary complications during follow up period. Then, we analyzed the factors related to recurrence. RESULTS: Indications for PTCS were cholangitis, symptomatic stone, liver abscess and biliary dilatation. Complete stone removal was achieved in 12 patients (63.2%). After receiving PTCS, the recurrence of intrahepatic stone related complication occurred in 52.6% (10/19) of patients during a median follow-up of 4.9 years (range, 1.8–7.8). Complications were cholangitis (5/10, 50%), cholangitis with liver abscess (3/10, 30%), liver abscess (1/10, 10%) and symptomatic stone (1/10, 10%). On univariate analysis, factors including multiple stone involvement, complete stone removal and bile duct stricture were not significantly associated with recurrent biliary complications. CONCLUSIONS: PTCS is an effective treatment for complications of recurrent intrahepatic stones in patients who have undergone hepatectomy. However, long term follow-up is necessary because of the recurrence of biliary complications.

Effects of Immunoglobulin Replacement on Asthma Exacerbation in Adult Asthmatics with IgG Subclass Deficiency

PURPOSE: Recurrent respiratory tract infection is a common manifestation of primary immunodeficiency disease, and respiratory viruses or bacteria are important triggers of asthma exacerbations. Asthma often coexists with humoral immunodeficiency in adults, and some asthmatics with immunoglobulin (Ig) G subclass deficiency (IgGSCD) suffer from recurrent exacerbations. Although some studies suggest a benefit from Ig replacement, others have failed to support its use. This study aimed to assess the effect of Ig replacement on asthma exacerbation caused by respiratory infection as well as the asthma control status of adult asthmatics with IgGSCD. METHODS: This is a multi-center, open-label study of adult asthmatics with IgGSCD. All patients received monthly intravenous immunoglobulin (IVIG) for 6 months and were evaluated regarding asthma exacerbation related to infection, asthma control status, quality of life, and lung function before and after IVIG infusion. RESULTS: A total of 30 patients were enrolled, and 24 completed the study. Most of the patients had a moderate degree of asthma severity with partly (52%) or uncontrolled (41%) status at baseline. IVIG significantly reduced the proportion of patients with asthma exacerbations, lowered the number of respiratory infections, and improved asthma control status, compared to the baseline values (P<0.001). The mean asthma-specific quality of life and asthma control test scores were improved significantly (P=0.009 and P=0.053, respectively); however, there were no significant changes in lung function. CONCLUSIONS: IVIG reduced the frequency of asthma exacerbations and improved asthma control status in adult asthmatics with IgGSCD, suggesting that IVIG could be an effective treatment option in this population.

Prediction of the Risk of Hepatocellular Carcinoma in Chronic Hepatitis C Patients after Sustained Virological Response by Aspartate Aminotransferase to Platelet Ratio Index

BACKGROUND/AIMS: Following sustained virological response (SVR) for chronic hepatitis C (CHC) infection, patients with advanced fibrosis require regular monitoring for hepatocellular carcinoma (HCC). The aspartate aminotransferase to platelet ratio index (APRI) is a simple noninvasive surrogate marker known to reflect fibrosis. METHODS: We retrospectively analyzed 598 patients who achieved SVR with interferon-based therapy for CHC. RESULTS: Over a median of 5.1 years of follow-up, there were eight patients diagnosed with HCC and a 5-year cumulative incidence rate of 1.3%. The median pretreatment APRI was 0.83, which decreased to 0.29 after achieving SVR (p<0.001). Both the pre- and posttreatment indices were associated with HCC development. The 5-year cumulative HCC incidence rates were 0% and 2.8% for patients with pretreatment APRI <1.0 and ≥1.0, respectively (p=0.001) and 0.8% and 12.8% for patients with posttreatment APRI <1.0 and ≥1.0, respectively (p<0.001). Pretreatment APRI at a cutoff of 1.0 had a 100% negative predictive value until 10 years after SVR. CONCLUSIONS: HCC development was observed among CHC patients who achieved SVR. The pre- and post-treatment APRI could stratify HCC risk, indicating that the APRI could be a useful marker to classify HCC risk in CHC patients who achieved SVR. However, given the small number of HCC patients, this finding warrants further validation.

Esophageal Mast Cell Infiltration in a 32-Year-Old Woman with Noncardiac Chest Pain

Noncardiac chest pain (NCCP) is one of the most common esophageal symptoms and lacks a clearly defined mechanism. The most common cause of NCCP is gastroesophageal reflux disease (GERD). One of the accepted mechanisms of NCCP in a patient without GERD has been altered visceral sensitivity. Mast cells may play a role in visceral hypersensitivity in irritable bowel syndrome. In this case, a patient with NCCP and dysphagia who was unresponsive to proton pump inhibitor treatment had an increased esophageal mast cell infiltration and responded to 14 days of antihistamine and antileukotriene treatment. We suggest that there may be a relationship between esophageal symptoms such as NCCP and esophageal mast cell infiltration.

Retraction: A Case of Rapid Progression of Hepatocellular Carcinoma after Radiofrequency Ablation

To preserve scientific integrity, Journal of Liver Cancer agreed with the authors that this paper be retracted.

DRESS syndrome with acute interstitial nephritis caused by quinolone and non-steroidal anti-inflammatory drugs / 영남의대학술지

Drug reaction with eosinophilia and systemic symptoms (DRESS) syndrome is a rare and severe drug-induced hypersensitivity syndrome characterized by hematological abnormalities and multiorgan involvement. Liver involvement is the most common visceral manifestation. However, renal failure has been rarely described. The common culprit drugs are anticonvulsants and allopurinol. We experienced a patient with DRESS syndrome with acute interstitial nephritis caused by concomitant administration of quinolone and non-steroidal anti-inflammatory drugs (NSAIDs). A 41-year-old man presented with a diffuse erythematous rash and fever which developed after administration of quinolone and NSAIDs for a month due to prostatitis. He was diagnosed with DRESS syndrome. Skin rash, fever, eosinophilia, and elevations of liver enzymes improved with conservative treatment and discontinuation of the causative drugs. However, deterioration of his renal function occurred on day 8 of admission. The levels of blood urea nitrogen and serum creatinine increased and oliguria, proteinuria and urinary eosinophils were observed. Ultrasonography showed diffuse renal enlargement. The clinical features were compatible with acute interstitial nephritis. Despite intravenous rehydration and diuretics, renal function did not improve. After hemodialysis, his renal function recovered completely within 2 weeks without administration of systemic corticosteroid.

A Case of Sorafenib-induced DRESS Syndrome in Hepatocelluar Carcinoma / 대한소화기학회지

Sorafenib is currently the only targeted therapy available for advanced stage hepatocellular carcinoma (HCC). Cutaneous adverse events associated with sorafenib treatment include hand-foot skin reaction, but there has been no report of drug reaction (or rash) with eosinophilia and systemic symptoms (DRESS) syndrome. Here, we report a case of 72-year-old man with HCC and alcoholic liver cirrhosis who developed skin eruptions, fever, eosinophilia, and deteriorated hepatic and renal function under sorafenib treatment. He has since successfully recovered with conservative care.

Management of Anaphylaxis / 대한내과학회지

Anaphylaxis is a life-threatening systemic hypersensitivity reaction with a rapid onset. All healthcare professionals should be familiar with its recognition and management. The clinical diagnosis is important. It involves the sudden onset of characteristic symptoms and signs within minutes to hours after exposure to a known or potential trigger, often followed by rapid progression over hours. Symptoms usually involve two or more body systems, including the skin and mucous membranes, and respiratory, gastrointestinal, cardiovascular, and central nervous systems. Prompt initial basic treatment with intramuscular epinephrine in the mid-anterolateral thigh can be life-saving. Simultaneously, it is important to place the patient in a supine position, call for help when indicated, provide supplemental oxygen, start intravenous fluid, and provide cardiopulmonary resuscitation as required, while monitoring the patient's vital signs and oxygenation status. Antihistamines and glucocorticoids are not initial treatments of choice. For self-management, patients at risk of anaphylaxis should carry epinephrine auto-injectors, have personalized emergency action plans, and follow-up with a physician about preventing anaphylaxis recurrence. Patient and caregiver training and education are essential in the management of anaphylaxis.

Three Cases of Overlap Syndrome Consisting of Systemic Sclerosis and Rheumatoid Arthritis / 대한내과학회지

Overlap syndrome is defined as a disease entity that fulfills the classification criteria of at least two different rheumatologic diseases simultaneously. Overlap of systemic sclerosis (SSc) and rheumatoid arthritis (RA) is less common than the overlap of polymyositis with SSc or systemic lupus erythematosus. Distinguishing RA from SSc can be difficult because arthralgia is a frequent symptom of both. We observed three cases of RA and SSc overlap. In each case, RA occurred in sequence with SSc, with a period of 4-15 years between the onset of each disease. In one case, the patient had diffuse SSc, which is rare among overlap syndrome patients. Previously, only one case of overlap syndrome involving SSc and RA has been reported in Korea; herein, we report our cases with a review of the literature.

Immunologic Evaluation of Patients with Cefotetan-Induced Anaphylaxis

Cefotetan is a commonly prescribed second-generation cephalosporin that acts against a wide range of bacteria. However, cefotetan-induced hypersensitivity has rarely been reported. We report 2 cases of cefotetan-induced anaphylaxis with immunologic evaluation. The first case was a 70-year-old asthmatic woman who had dyspnea and hypotension during administration of cefotetan, in which high serum-specific IgE to cefotetan-human serum albumin (HSA) conjugate was detected by enzyme-linked immunosorbent assay. The second case was a 63-year-old asthmatic woman who complained of chest tightness and dyspnea during cefotetan infusion, in which high serum-specific IgG1 and IgG4 with no serum specific IgE to cefotetan-HSA conjugate was detected. The basophil activation test using basophils from the patient showed a significant up-regulation of CD63 with the addition of anti-IgG4 antibody compared with that in non-atopic healthy controls. In conclusion, cefotetan can induce anaphylaxis, which may involve both IgE- and IgG4-mediated responses in the pathogenic mechanism.

Pituitary Granulomatosis with Polyangiitis Presenting with Central Diabetes Insipidus

We report on a case of limited form of granulomatosis with polyangiitis (GPA) with pituitary involvement which presented with central diabetes insipidus. This rare form of GPA has not been reported in Korea. The patient presented with fever, headache, productive cough, nasal symptoms, and polyuria. Laboratory data and imaging studies demonstrated inflammatory lesions in nasal sinus and lungs. Pituitary stalk thickening and enhancement were observed on brain magnetic resonance imaging. The histopathology of the lung lesions showed chronic active granulomatous inflammation. Polyuria, hyperosmolar hypernatremia, and decreased urine osmolality which responded to synthetic vasopressin analog were consistent with central diabetes insipidus. Based on the clinical findings and histopathological results, a diagnosis of GPA with pituitary involvement was established. Treatment with desmopressin as well as concurrent glucocorticoids and immunosuppressant resulted in clinical improvement.

Predictors of Asthma Control by Stepwise Treatment in Elderly Asthmatic Patients

The geriatric population is increasing, and asthma severity increases with age. We determined the predictors of asthma control, exacerbation, and the factors that affect asthma-specific quality of life (A-QOL) in elderly asthmatic patients. This was a prospective, multicenter, real-life study for 6 months with stepwise pharmacologic treatment based on the Global Initiative for Asthma (GINA) guideline. A total of 296 asthmatic patients aged > or = 60 yr were recruited from 5 university centers in Korea. The improved-asthma control group was defined as the group of patients who maintained well-controlled or improved disease and the not-improved asthma control group was defined as the remaining patients. Fewer number of medications for comorbidities (2.8 +/- 3.3 in the improved vs. 4.5 +/- 4.4 in the control) and higher physical functioning (PF) scale (89.8 +/- 14.2 in the improved vs. 82.0 +/- 16.4 in the control) were significant predictors in the improved-asthma control group (OR = 0.863, P = 0.004 and OR = 1.028, P = 0.018, respectively). An asthma control test (ACT) score of < or = 19 at baseline was a significant predictor of asthma exacerbation (OR = 3.938, P = 0.048). Asthma duration (F = 5.656, P = 0.018), ACT score (F = 12.237, P = 0.001) at baseline, and the presence of asthma exacerbation (F = 5.565, P = 0.019) were significant determinants of changes in A-QOL. The number of medications for comorbidities and performance status determined by the PF scale may be important parameters for assessing asthma control in elderly asthmatic patients.

A Case of Rapid Progression of Hepatocellular Carcinoma after Radiofrequency Ablation

The therapeutic effectiveness and safety of radiofrequency ablation (RFA) for hepatocellular carcinoma (HCC) have been clinically established, and the procedure is now generally accepted as a curative treatment for very early or early stage HCC. Recently, we observed an aggressive recurrence after RFA for HCC in 50 year-old female. RFA was performed for a 2.7 cm sized HCC, which was completely ablated. However, 7 months later, aggressive intrahepatic recurrence was observed. Herein, we report a case with a discussion.

Rheumatoid Nodulosis with Recurrent Nodules: A Case Report / 대한내과학회지

Rheumatoid nodulosis, a benign variant of rheumatoid arthritis (RA), is a rare condition characterized by multiple subcutaneous nodules and positive rheumatoid factor in the absence of systemic manifestations or joint disease. Asymptomatic nodules rarely require treatment, and are unlikely to recur after excision, except in cases in which RA develops. Here, we describe an unusual case of recurrent rheumatoid nodulosis in a 42-year-old female presenting with recurrent subcutaneous nodules on the plantar side of her left foot, which caused pain when walking. Nodules were initially excised to control symptoms; however, since the excision, the nodules have recurred twice in the absence of other RA symptoms.

Seasonal and regional variations in the causes of anaphylaxis in Korean adults

PURPOSE: To investigate whether causes of anaphylaxis vary according to regions and seasons in Korean adults. METHODS: Based on previous retrospective studies of anaphylaxis between 2007 and 2011 at the 15 university hospitals. Regions were classified into 4 groups: region I, Seoul; region II, Gyeonggi; region III, Chungcheong; and region IV, Chonnam and Busan. The cases induced by 5 major allergens including drugs, food, bee sting, radiocontrast media, and exercise, were analyzed in the present study. RESULTS: Among a total of 1,661 cases reported (53% male, 45.9+/-16.0 years), 367 (22.2%), 706 (42.5%), 319 (19.2%), and 269 cases (16.2%) were enrolled in regions I, II, III, and IV, respectively. Of the 5 major allergens, drugs (37.3%) were the most frequently reported, followed by food (25.7%), bee sting (17.9%), radiocontrast media (12.9%), and exercise (6.2%). There was no significant difference in the total occurrence of anaphylaxis in 4 seasons (374 in spring, 460 in summer, 460 in autumn, and 367 in winter). Multiple logistic regression analysis revealed that drug-induced anaphylaxis was significantly associated with the winter season (odds ratio [OR] 1.0 vs. OR 0.597, P<0.05 for spring; OR 1.0 vs. OR 0.481, P<0.01 for summer; OR 1.0 vs. OR 0.653, P<0.05 for autumn). Food-associated anaphylaxis was mainly reported in region I, whereas the frequency of insect sting was relatively higher in regions II, III, and IV than in region I. Older age and female gender were significantly associated with drug-induced anaphylaxis. CONCLUSION: Specific causative allergens of anaphylaxis in adults may vary according to age, gender, region, and season in Korea.

Comparison of skin prick test and serum specific IgE measured by ImmunoCAP system for various inhalant allergens

PURPOSE: It appears that much of the discordance between skin prick test (SPT) and ImmunoCAP in clinical practice. We investigated the comparison and correlation between SPT and ImmunoCAP for inhalant allergens. METHODS: A total of 1,400 patients who were tested SPT and ImmunoCAP were recruited from June 2011 to May 2014 in Dong-A University Hospital, and the results of two assays were compared for 17 inhalant allergens. For SPT, mean wheal size> or =3 mm or allergen/histamine> or =1 at 15 minutes, and the result of ImmunoCAP of > or =0.35 kU/L was considered positive, respectively. RESULTS: Of the study subjects, bronchial asthma was 29.3%, rhinitis 36.8%, atopic dermatitis 0.6%, and chronic urticaria 4.3%. The agreement rate of between two assays was 77.4%. When ImmunoCAP was compared with SPT as the reference, the sensitivity, specificity was 75.5% and 80.0%, respectively. Significant correlation was observed (r=0.59), and birch, mugwort, Japanese hop, house dust mites, and cockroach showed very strong correlation (r>0.7). CONCLUSION: The agreement, sensitivity, and specificity between SPT and ImmunoCAP was various according to allergens. We should determine the clinical relevance of the allergen sensitization using both SPT and ImmunoCAP not alone with combination of clinical symptoms.

Predictors of the Severity and Serious Outcomes of Anaphylaxis in Korean Adults: A Multicenter Retrospective Case Study

PURPOSE: Differences in definitions of the condition, relevant triggers, and the geographical locations of study centers, cause estimates of the prevalence of anaphylaxis to vary. Recent epidemiological data indicate that the incidence of anaphylaxis is rising. METHODS: To investigate the causes and clinical features of anaphylaxis in Korean adults, factors associated with the severity of the condition, and serious outcomes, a retrospective medical record review was performed on adult patients diagnosed with anaphylaxis between 2007 and 2011 in 15 University Hospitals of South Korea. RESULTS: A total of 1,806 cases (52% male, age 16-86 years) were reported. Cutaneous symptoms (84.0%), combined with respiratory (53.9%) and/or cardiovascular (55.4%) symptoms, were the most frequent presentations. Using a recognized grading system, 1,776 cases could be classified as either mild, 340; moderate, 690; or severe, 746. Although eliciting factors varied significantly by age, gender, and regional and seasonal factors, drugs (46.5%; including nonsteroidal anti-inflammatory drugs, antibiotics, and radiocontrast media) were the most common cause of anaphylaxis, followed by foods (24.2%), insect stings (16.4%), exercise (5.9%), and unknown etiology (7.0%). All of age, multi-organ involvement, a history of allergic disease, and drug-induced anaphylaxis, were significant predictors of serious outcomes requiring hospital admission or prolongation of hospital stay. Epinephrine auto-injectors were prescribed for 7.4% of reported cases. CONCLUSIONS: The principal causes of anaphylaxis in Korean adults were drugs, food, and insect stings. Drug-associated anaphylaxis, a history of allergic disease, multi-organ involvement, and older age, were identified as predictors of serious outcomes.

Prevalence and Risk Factors for Depression in Korean Adult Patients with Asthma: Is There a Difference between Elderly and Non-Elderly Patients?

Depression is an important comorbidity of asthma. However, little information is available about depression and its potential impact on asthma control in Korean adult asthma patients. We aimed to estimate the prevalence and risk factors for depression in Korean adults with persistent asthma. The 127 non-elderly (20-64 yr) and 75 elderly (> or =65 yr) patients with asthma were recruited. Demographic and clinical data were extracted, and the patients completed the Asthma Specific Quality of Life (AQOL) questionnaire and asthma control test (ACT). Depression status was defined using the Korean version of the Patient Health Questionnaire-9 (PHQ-9). Depression was more prevalent in non-elderly (18.9%) than in elderly patients with asthma (13.3%). Patients with depression were significantly younger, had lower economic status, shorter disease duration, poorer asthma control, and worse AQOL scores (P<0.05). Within the non-elderly group, younger age and shorter disease duration were significantly associated with depression (P<0.05). Within the elderly group, a higher body mass index and current smoking status were significantly associated with depression (P<0.05). The PHQ-9 score was significantly correlated with worse ACT and AQOL scores in both groups. In conclusion, depression is strongly associated with poor asthma control and quality of life in Korean adult asthma patients. Our results provide important clues that used to target modifiable factors which contribute to development of depression in asthma patients.

Cefepime-induced encephalopathy without renal impairment

Cefepime is an extended-spectrum, fourth-generation cephalosporin that has been widely used for approved indications such as febrile neutropenia. Common adverse events of cefepime include headache, skin rash, gastrointestinal problems, and fever. However, encephalopathathy caused by cefepime has been sporadically reported worldwide over the last decade. We experienced a rare case of cefepime-induced encephalopathy. A 75-year-old man with a 30-year history of chronic obstructive pulmonary disease was admitted to the medical intensive care unit under a diagnosis of pneumonia. Initial antibiotic therapy was started with piperacillin/sulbactam and ciprofloxacin. His condition was improved with this treatment. About 2 months later, his condition was aggravated again, with mild fever and purulent sputum. Intravenous cefepime was selected on the basis of antibiotic susceptibility to Pseudomonas aeruginosa isolated from his sputum. However, his mentality became drowsy 48 hours after cefepime adminstration. He showed tremors and right facial paralysis. Neurologic examination for motor power and sensory function revealed normal findings. Laboratory tests, including serum electrolytes, glucose, osmolality, and ammonia, gave normal results. Brain magnetic resonance imaging showed chronic ischemic and atropic changes, and an electroencephalography revealed triphasic waves. The administration of cefepime was stopped, and his symptoms started to improve within 48 hours. Electroencephalography results became normalized, and he completely recovered within 48 hours after discontinuation of cefepime.

Serotonin syndrome associated with linezolid

Serotonin syndrome (SS) is a potentially life-threatening drug reaction characterized by mental status change, increased neuromuscular tone, and autonomic instability. Linezolid, an oxazolidinone antibacterial agent, is widely used in general hospitals; however, it interacts with some serotonin agonists and may cause SS. We report a case of SS caused by linezolid, without the concomitant use of serotonin agonist. A 72-year-old patient was admitted due to recurrent wound infection of his left ankle. He developed fever, skin rash, and renal function deterioration, and blood eosinophils and liver enzymes increased after administration of vancomycin. The antibiotic was changed to linezolid against methicillin-resistant Staphylococcus aureus. Four days later, he developed agitation, fever, increased blood pressure, and tachycardia. There were no abnormal findings in laboratory and image tests, including brain and chest computed tomography suggesting the cause of his symptoms. He had not taken any serotonin agonists, including serotonin uptake inhibitors and monoamineoxidase-inhibiting antidepressants. When administration of linezolid was stopped, his symptoms improved within 24 hours and fully recovered within 2 days without additional treatments.