Cytomegalovirus Colitis Causing Cecal Perforation and Massive Lower Gastrointestinal Bleeding / 대한소화기내시경학회지

Cytomegalovirus (CMV) infection is associated with significant morbidity and mortality in immunocompromised patients. It may cause serious illness including bleeding, ulceration and perforation of the gastrointestinal tract. However, bowel perforation, toxic megacolon, and massive lower gastrointestinal bleeding caused by CMV in one patient is not common. In this report, we present a case of CMV colitis causing cecal perforation and massive lower gastrointestinal bleeding in a patient with lupus nephritis. In our case, severe lower gastrointestinal bleeding developed during successful treatment of CMV infection with ganciclovir. Even though the outcome of CMV colitis has improved since ganciclovir has been available for immunocompromised patients, reductions in gastrointestinal bleeding from colonic ulcers of CMV colitis may be possible during successful treatment with ganciclovir. This case suggests the possibility of lower gastrointestinal bleeding from a colon ulcer of CMV colitis should be considered during successful treatment with ganciclovir in immunocompromised patients.

A Case of Rectal Metastasis from Primary Signet Ring Cell Carcinoma of the Colon / 대한소화기내시경학회지

Rectal metastasis of colon cancer without peritoneal carcinomatosis is a rare condition whose initial clinical presentation may mimic inflammation. To the best of our knowledge, there was no report on such cases. A 45-year-old man with a history of left hemicolectomy and adjuvant chemotherapy for primary signet ring cell carcinoma (SRCC) of the descending colon, admitted to have constipation and abdominal pain for 3 weeks. His colonoscopic findings did not show local tumor recurrence at the anastomsis site, however, a hard, concentric luminal narrowing of the lower rectum was encountered. Endoscopic biopsies revealed chronic inflammations, and positron emission tomography with 18F-fluorodeoxyglucose revealed diffuse mildly hypermetabolic lesion in the rectum, suggesting inflammation. Magnetic resonance image showed submucosal wall thickening with multiple perirectal lymph nodes. Rectal metastasis of colon cancer was highly suspected clinically and a surgical biopsy confirmed SRCC which was surgically removed thereafter.

The Prognostic Factors of Pancreatic Cancer Can be Different according to Clinical Stages / 대한소화기학회지

BACKGROUND/AIMS: The prognosis of patients with pancreatic cancer remains very poor. Although many studies have evaluated the prognostic factors of pancreatic cancer, their results are inconclusive because of different inclusion criteria, tumor stages, and treatment modalities. This large scale retrospective analysis was performed to assess whether active treatment of pancreatic cancer, even in its advanced stage, could improve patients' survival. In addition, we sought to identify factors associated with favorable prognosis of pancreatic cancer. METHODS: Between 1994 and 2004, a total of 971 patients with pancreatic cancer were treated at Asan Medical Center. The patients were classified into three groups according to clinical stages: resectable (RE, n=226), locally advanced (LA, n=409), and far advanced (FA, n=336). Treatment response and prognostic factors for survival were analyzed in each group. RESULTS: Compared to supportive care, active treatment significantly increased the median survival time in all groups (RE: 18.0 vs. 9.0 months; LA: 10.0 vs. 7.0 months; FA: 5.0 vs. 3.0 months). Multivariate analysis showed that prognostic factors for survival differed according to clinical stages. In the RE group, unfavorable prognostic factors were high CA 19-9, poor histologic differentiation, large tumor size, and regional lymph node involvement. In the FA group, however, poor outcomes were associated with old age, poor performance status, and hypoalbuminemia. CONCLUSIONS: More active treatment of pancreatic cancer, even in advanced stage, can make a significant difference in terms of patient's survival. The prognosis of resectable pancreatic cancer is dependent on tumor-related factors, while the prognosis of patients with far advanced pancreatic cancer is dependent on patient-related factors.

A case of primary effusion lymphoma / 대한내과학회지

A 78-year-old woman was referred to this hospital because of exertional dyspnea for 2 weeks. Although she was treated with anti-tuberculous medication under the assumption that she had tuberculous pleuritis, her dyspnea continued. Physical examination revealed diminished breath sounds over the left lung field. Chest radiography showed a large left pleural effusion. The pleural effusion revealed malignant cell dominant exudates with a high adenosine deaminase level. Serological tests were negative for HIV. Computed tomography scan of the chest and abdomen showed pleural effusion, but no mass or pathological lymph nodes were detected. The biopsy specimen of the pleura was diagnosed as malignant B cell lymphoma with plasmacytoid features, suggesting a possibility of primary effusion lymphoma. Polymerase chain reaction assay of tumor was positive for HHV-8 DNA. She underwent pleurodesis during Video-Assisted Thoracic Surgery, and her dyspnea subsequently improved.

A Case of Vertebral Osteomyelitis due to Mycobacterium intracellulare

We report a case of vertebral osteomyelitis due to Mycobacterium intracellulare in a 60-year-old man without predisposing conditions. He was successfully treated with surgical excision of the inflamed tissue and combined antimycobacterial therapy consisting of clarithromycin, ethambutol, and rifampin. In this case, polymerase chain reaction-restriction fragment length polymorphism analysis (PCR-RFLP) based on the rpo B gene of cultured isolates allowed rapid identification of M. intracellulare. Although very rare, nontuberculous mycobacteria (NTM) should be suspected as a causative pathogen of vertebral osteomyelitis. To the best of our knowledge, this is the first case of vertebral osteomyelitis caused by NTM reported in the Korean literature.

A Case of Vertebral Osteomyelitis due to Mycobacterium intracellulare

We report a case of vertebral osteomyelitis due to Mycobacterium intracellulare in a 60-year-old man without predisposing conditions. He was successfully treated with surgical excision of the inflamed tissue and combined antimycobacterial therapy consisting of clarithromycin, ethambutol, and rifampin. In this case, polymerase chain reaction-restriction fragment length polymorphism analysis (PCR-RFLP) based on the rpo B gene of cultured isolates allowed rapid identification of M. intracellulare. Although very rare, nontuberculous mycobacteria (NTM) should be suspected as a causative pathogen of vertebral osteomyelitis. To the best of our knowledge, this is the first case of vertebral osteomyelitis caused by NTM reported in the Korean literature.

Calcium-Sensing Receptor Gene Polymorphism is Associated with the Parathyroid Response to Low Calcium Dialysate in Hemodialysis Patients with Low Parathyroid Hormone Secretion / 대한신장학회지

PURPOSE: Low level of parathyroid hormone (PTH) is a risk factor that might cause hip fracture in dialysis patients. Low calcium dialysate (LCD) has been suggested as an approach to increase PTH level. The calcium-sensing receptor (CaSR) polymorphism is known to be associated with the sensitivity to extracellular calcium. METHODS: We prospectively investigated the role of genetic polymorphism of CaSR codon 990 as one cause of the different parathyroid responses to LCD in maintenance hemodialysis (HD) patients. 48 patients, using 3.5 mEq/L calcium dialysate, with intact PTH below 100 pg/ml for the last one year underwent HD sessions on 2.5 mEq/L calcium dialysate for 12 weeks. Serum intact PTH, total calcium, phosphorus, alkaline phosphatase (ALP) and bone-specific ALP (BAP) were measured monthly. The CaSR gene from peripheral lymphocytes was amplified to confirm the genotype by polymerase chain reaction. RESULTS: According to the CaSR genetic polymorphism, subjects were divided into 3 groups, A/A (14.6 %), A/G (45.8%) and G/G (39.6%). Twelve weeks later, intact PTH (48.5+/-25.4 to 89.0+/-49.4 pg/mL, p<0.01), and ALP (78.7+/-25.7 to 87.4+/-27.2 IU/L, p<0.01) increased significantly in G/G group, but not in non-G/G groups. However, BAP significantly increased in both G/G group (24.3+/-11.9 to 29.5+/-10.6 U/L, p<0.01) and in non-G/G groups (21.4+/-4.5 to 26.1+/-9.1 U/L, p<0.01). During the study period, levels of corrected total calcium and phosphorus were not significantly changed. CONCLUSION: The CaSR polymorphism, G/G genotype, strongly influenced the responsiveness of parathyroid gland to LCD, compared with non-G/G genotypes. However, bone formation may occur actively on LCD, irrespective of CaSR genetic polymorphism.