Acute respiratory distress syndrome associated with scrub typhus: diffuse alveolar damage without pulmonary vasculitis

Pathologic findings of scrub typhus have been characterized by vasculitis of the microvasculature of the involved organ resulting from a direct invasion by Orientia tsutsugamushi. We experienced a case of acute respiratory distress syndrome (ARDS) associated with scrub typhus. The case was proven by eschar and high titer of serum IgM antibody (positive at 1:1280). Open lung biopsy showed diffuse alveolar damage (DAD) in the organizing stage without evidence of vasculitis. Immunofluorescent antibody staining and polymerase chain reaction for O. tsutsugamushi failed to demonstrate the organism in the lung tissue. The patient expired due to progressive respiratory failure despite doxycycline therapy. Immunologic mechanism, without direct invasion of the organism, may participate in the pathogenesis of ARDS associated with scrub typhus.

A Case of Bilateral Lung Volume Reduction Surgery in Severe Emphysema / 결핵

Lung volume reduction surgery, resecting the most severely affected regions of emphysema, was designed to improve quality of life for selected patients with severe emphysema. We report a case of a 72 year old severe emphysema patient who received bilateral lung volume reduction surgery and showed marked improvement of quality of life and lung function.

A prospective study for spectrum and frequency of chronic cough in patients visiting out-patient clinic / 천식및알레르기

BACKGROUND: Chronic cough is commonly defined as a persistent or recurrent cough exceeding 3 weeks duration and the prevalence of chronic cough is reported to range from 14-23% among non-smoking adults. Irwin et al previously reported that common causes of chronic cough are postnasal drip syndrome asthma, and gastroesophageal reflux using the anatomic and diagnostic protocol. OBJECTIVE: To determine the spectrum and frequency of chronic cough and to aid establishing algorithmic approach for chronic cough. MATERIALS AND METHOD: We prospectively evaluated 105 consecutive and unselected immunocompetent patients complaining of chronic cough utilizing modified anatomic and diagnostic protocol proposed by Irwin et al. Initial diagnosis was made by history, physical examination and laboratory test including spirometry, methacholine provocation test, and 24 hour pH monitoring. Specific treatment was done based upon initial diagnosis and cough score was compared before and after treatment. Reassessment was done in case of treatment failure. RESULT: The causes of cough were determined in 100 of 105 patients(95% ). Cough was due to one condition in 94.8% and two in 15.2%. 121 causes of cough were identified and their spectrum and frequency were found to be postnasal drip syndrome (39.3% ), asthma (32.2% ), gasteroesophageal reflux (14.1%), chronic bronchitis (5.0%), others (4.1%: drug-induced, bronchiolitis, endobronchial tuberculosis, and lung cancer). History about nasal symptoms was useful, but history about gastroesophageal reflux were not useful for the diagnosis. CONCLUSION: The results suggest that anatomic and diagnostic approach for evaluating chronic cough is also useful in Korea and the most common causes of chronic cough are postnasal drip syndrome, asthma and gastroesophageal reflux.

A case of Tocolytics Induced Pulmonary Edema / 결핵

Tocolytics are agents widely used in the treatment of premature labor to inhibit uterine contractions. Ritodrine is most commonly used tocolytic agent and acts by increasing intracellular cyclic adenosine monophosphate, which decreases the activity of myosin light-chain kinase, the rate-limiting enzyme in the signal network leading to contraction. Physiologic effects associated with the use of ritodrine are due to their effect on beta-1 as well as beta-2 receptors. Some of material complications o? therapy are tachycardia, hyperglycemia, hypokalemia, lactic acidosis, myocardial ischemia, and pulmonary edema. Tocolytic induced pulmonary edema is a serious complication that can lead to marternal death, although infrequent. The incidence varies from 0.5% to 5% of those receiving these agents. Predisposing factors include the concommitant use of corticosteroid, twin gestation, fluid overload(particularly with saline), and anemia. Several mechanisms have been postulated, but the pathogenesis is uncertain. It is suggested that both types of mechanism, hydrostatic and Permeability induced, might be involved. The association of tocolytic therapy with pulmonary edema appears to be unique to the pregnant state, because this complication has never been reported in asthmatic patients exposed to high dosages. We report a case of tocolytic induced pulmonary edema developed in 24 hours after delivery.

Measurement of Ventilatory Threshold in the Patients with Chronic Airway Obstruction / 결핵

BACKGROUND: There are many suggested methods for the indirect determination of anaerobic threshold(AT) using the changes of ventilatory parameters in respones to ventilatory load accompanying the increase of blood lactic acid level during exercise and the threshold derived from them is called ventilatory threshold( VT). They include ventilatory equivalent method(VEM), End-tidal PO2 method(PETO2), V-slope method(VSM), and respiratory quotient method(RQ). But in the patients with chronic airway ohstruction(CAO), the AT determined by ventilatory methods may not reflect true AT because the patients with GAO show inadequate ventilatory response to the increase of blood lactic acid level during excercise. METHODS: For the investigation of detection rate and reliability of above four VT determination methods in the patients with GAO, we performed the symptom-limited and maximal incremental exercise test in 17 patients with GAO and 12 normal controls. The incremental workload was 10 W/min in GAO group and 25 W/min in control group. The reliability of VT in each group was investigated by the calculation of Spearman correlation coefficient. RESULTS: The detection rates of VT were 100% by RQ, 91.7% by both VEM and POETO2, and 83.3% by VSM in normal control group, while 94.1% by RQ, 64.7% by VEM and PETO2, and 83.3% by VSM in GAO group. Good correlations were noted among VEM, PETO2, and VSM except RQ in normal control group. But there was no significant correlation except between VEM and PETO2 in GAO group. CONCLUSIONS: RQ is very sensitive but crude and VEM is near similar to PETO2. The clinical usefulness of VT determined by ventilatory method might be limited in patients with severe GAO.

Occult Papillary Thyroid Carcinoma Presenting as a Metastatic Pleural Effusion / 결핵

Although papillary carcinoma of the thyroid generally follows an indolent course characterized by slow growth and the absence of distant metastases, several available reports suggest that metastasis to bone and/or lung parenchyma may occur infrequently. But pleural metastases are known to be very rare, so there have been only two case reports about the pleural metastases of papillary thyroid carcinoma in the literatures. Even the case of occult papillary thyroid carcinoma presenting as a metastatic pleural effusion has been never been reported. Recently we experienced a case with the chief complaint of dyspnea due to massive pleural effusion, the cytologic examination of which revealed the papillary carcinoma with psamomma bodies. The examination of the thyroid revealed no definite primary tumor. The total thyroidectomy was done with the plan of post-operative radioactive iodine treatment and the pathologic result confirmed the occult papillary microcarcinoma as expected. With the present case report, the extension of the clinical spectrum of metastatic papillary carcinoma of the thyroid is expected.