Real-world effectiveness and safety of ustekinumab induction therapy for Korean patients with Crohn’s disease: a KASID prospective multicenter study

Background/Aims@#We investigated the real-world effectiveness and safety of ustekinumab (UST) as induction treatment for Koreans with Crohn’s disease (CD). @*Methods@#CD patients who started UST were prospectively enrolled from 4 hospitals in Korea. All enrolled patients received intravenous UST infusion at week 0 and subcutaneous UST injection at week 8. Clinical outcomes were assessed using Crohn’s Disease Activity Index (CDAI) scores at weeks 8 and 20 among patients with active disease (CDAI ≥150) at baseline. Clinical remission was defined as a CDAI <150, and clinical response was defined as a reduction in CDAI ≥70 points from baseline. Safety and factors associated with clinical remission at week 20 were also analyzed. @*Results@#Sixty-five patients were enrolled between January 2019 and December 2020. Among 49 patients with active disease at baseline (CDAI ≥150), clinical remission and clinical response at week 8 were achieved in 26 (53.1%) and 30 (61.2%) patients, respectively. At week 20, 27 (55.1%) and 35 (71.4%) patients achieved clinical remission and clinical response, respectively. Twenty-seven patients (41.5%) experienced adverse events, with serious adverse events in 3 patients (4.6%). One patient (1.5%) stopped UST therapy due to poor response. Underweight (body mass index <18.5 kg/m2) (odds ratio [OR], 0.085; 95% confidence interval [CI], 0.014–0.498; P=0.006) and elevated C-reactive protein at baseline (OR, 0.133; 95% CI, 0.022–0.823; P=0.030) were inversely associated with clinical remission at week 20. @*Conclusions@#UST was effective and well-tolerated as induction therapy for Korean patients with CD.

Bronchoesophageal fistula in a patient with Crohn’s disease receiving anti-tumor necrosis factor therapy

Tuberculosis is an adverse event in patients with Crohn’s disease receiving anti-tumor necrosis factor (TNF) therapy. However, tuberculosis presenting as a bronchoesophageal fistula (BEF) is rare. We report a case of tuberculosis and BEF in a patient with Crohn’s disease who received anti-TNF therapy. A 33-year-old Korean woman developed fever and cough 2 months after initiation of anti-TNF therapy. And the symptoms persisted for 1 months, so she visited the emergency room. Chest computed tomography was performed upon visiting the emergency room, which showed BEF with aspiration pneumonia. Esophagogastroduodenoscopy with biopsy and endobronchial ultrasound with transbronchial needle aspiration confirmed that the cause of BEF was tuberculosis. Anti-tuberculosis medications were administered, and esophageal stent insertion through endoscopy was performed to manage the BEF. However, the patient’s condition did not improve; therefore, fistulectomy with primary closure was performed. After fistulectomy, the anastomosis site healing was delayed due to severe inflammation, a second esophageal stent and gastrostomy tube were inserted. Nine months after the diagnosis, the fistula disappeared without recurrence, and the esophageal stent and gastrostomy tube were removed.

Medication Adherence in Korean Patients with Inflammatory Bowel Disease and Its Associated Factors / 이화의대지

Objectives@#It is important that inflammatory bowel disease (IBD) patients adhere to their prescribed medication regimens to avoid the repeat exacerbations, complications, or surgeries associated with this disorder. However, there are few studies on medication adherence in patients with IBD, especially in Asian populations. So, we analyzed the factors associated with medication adherence in Korean IBD patients. @*Methods@#Patients who had been diagnosed with Crohn’s disease (CD) or ulcerative colitis (UC) more than 6 months previously and receiving oral medications for IBD were enrolled. Medication adherence was measured using the Medical Adherence Reporting Scale (MARS-5), a self-reported medication adherence measurement tool. @*Results@#Among 207 patients in the final study population, 125 (60.4%) had CD and 134 (64.7%) were men. The mean age was 39.63 years (SD, 13.16 years) and the mean disease duration was 10.09 years (SD, 6.33 years). The mean medication adherence score was 22.46 (SD, 2.86) out of 25, and 181 (87.4%) patients had score of 20 or higher.In multiple linear regression analysis, self-efficacy (β=0.341, P<0.001) and ≥3 dosing per day (β=–0.192 P=0.016) were revealed to be significant factors associated with medication adherence. Additionally, there was a positive correlation between self-efficacy and medication adherence (r=0.312, P<0.001). However, disease related knowledge, depression, and anxiety were not significantly associated with medication adherence. @*Conclusion@#To improve medication adherence among patients with IBD, a reduction in the number of doses per day and an improved self-efficacy will be helpful.

Palonosetron-Induced Anaphylaxis During General Anesthesia: A Case Report

Palonosetron is a 5-hydroxytryptamine-3 (5-HT-3) receptor antagonist used for preventing postoperative nausea and vomiting. Compared with ondansetron and granisetron, it is a better drug because of prolonged action and minimal side effects. Some adverse effects of palonosetron have been reported. In this report, we describe a 37-year-old male who developed severe hypersensitivity reactions to palonosetron during surgery for kidney donation. His medical history was unremarkable, except for inguinal hernia with herniorrhaphy 8 years ago. The surgery was uneventful until 2 hours 20 minutes. After palonosetron injection, his blood pressure dropped to 80/50 mm Hg, and facial edema, rash, conjunctival swelling, and wheezing developed. The patient was resuscitated by administration of ephedrine, hydrocortisone, and peniramine. Following the surgery, the patient was monitored for 3 days, and there were no subsequent anaphylactic reactions or other complications. The skin test on postoperative day 54 was positive for hypersensitivity to palonosetron. Although palonosetron is known for its safety, other hypersensitivity events have been reported. Ondansetron is another widely used 5-HT-3 antagonist, which has been reported to cause anaphylaxis. Therefore, clinicians should be aware of the possibility of patients experiencing severe adverse reactions to palonosetron.

Refractory Pleural Effusion in Systemic Lupus Erythematosus Treated by Pleurectomy

Pleural effusion is a common pulmonary manifestation of systemic lupus erythematosus (SLE) and often occurs as bilateral exudative pleural effusion. The condition usually responds quickly to corticosteroid therapy. However, massive pleural effusion refractory to immunosuppressive drugs has rarely been reported; thus, the proper therapeutic modality is largely decided on a case-by-case basis. In this case, we describe successful treatment with surgical pleurectomy for massive refractory pleural effusion in a patient with SLE.

Vertebral Osteomyelitis Caused by Mucormycosis / 대한내과학회지

Mucormycosis is a rare but fatal disease and usually affects the rhinocerebrum, lungs, traumatic wounds or surgical sites. Vertebral osteomyelitis due to mucormycosis is very rare, with only three cases caused by mucormycosis since 1970 being reported, and none in Korea. Here, we present a case of vertebral osteomyelitis caused by mucormycosis in a 67-year-old woman, having type 2 diabetes mellitus for 10 years, who was in complete remission from acute leukemia after chemotherapy 3 years previously.

Surgical Removal of Migrated Coil after Embolization of Jejunal Variceal Bleeding: A Case Report / 대한소화기학회지

Jejunal variceal bleeding is less common compared with esophagogastric varices in patients with portal hypertension. However, jejunal variceal bleeding can be fatal without treatment. Treatments include surgery, transjugular intrahepatic porto-systemic shunt (TIPS), endoscopic sclerotherapy, percutaneous coil embolization, and balloon-occluded retrograde transvenous obliteration (BRTO). Percutaneous coil embolization can be considered as an alternative treatment option for those where endoscopic sclerotherapy, surgery, TIPS or BRTO are not possible. Complications of percutaneous coil embolization have been reported, including coil migration. Herein, we report a case of migration of the coil into the jejunal lumen after percutaneous coil embolization for jejunal variceal bleeding. The migrated coil was successfully removed using surgery.

Fluoroscopy-Guided Endoscopic Removal of Foreign Bodies

In most cases of ingested foreign bodies, endoscopy is the first treatment of choice. Moreover, emergency endoscopic removal is required for sharp and pointed foreign bodies such as animal or fish bones, food boluses, and button batteries due to the increased risks of perforation, obstruction, and bleeding. Here, we presented two cases that needed emergency endoscopic removal of foreign bodies without sufficient fasting time. Foreign bodies could not be visualized by endoscopy due to food residue; therefore, fluoroscopic imaging was utilized for endoscopic removal of foreign bodies in both cases.

Cholangiocarcinoma Masquerading as IgG4-related Sclerosing Cholangitis / 대한췌담도학회지

IgG4-related sclerosing cholangitis (IgG4-SC) represents a rare but clinically challenging differential diagnosis in patients with biliary strictures which can be mistaken for cholangiocarcinoma. We present a case of a 73-year-old male presented with abdominal discomfort and weight loss. Biliary images showed long-segment luminal narrowing of extrahepatic bile duct associated with prominent enhanced wall thickening, but luminal patency was preserved. Pancreatic images revealed segmental irregular narrowing of main pancreatic duct without upstream duct dilatation. His liver function tests and CA19-9 level were normal. Putting all findings together, IgG4-SC associated with autoimmune pancreatitis was strongly suspected. However, endobiliary biopsy of extrahepatic bile duct revealed adenocarcinoma which was not resectable due to celiac axis involvement. Because there is an overlap in biliary imaging findings between IgG4-SC and cholangiocarcinoma, biopsy is essential for adequate differential diagnosis. We present a case of cholangiocarcinoma masquerading as IgG4-SC based on clinical and imaging findings.

Septic Shock due to Unusual Pathogens, Comamonas testosteroni and Acinetobacter guillouiae in an Immune Competent Patient / 대한구급학회지

Comamonas testosteroni and Acinetobacter guillouiae are gram-negative bacilli of low virulence that are widely distributed in nature and normal flora. Despite their common occurrence in environments, they rarely cause infectious disease. We experienced a case of septic shock by C. testosterone and A. guillouiae, and isolated them by 16S ribosomal RNA sequencing method from the blood cultures of a previous healthy female during postoperative supportive care. This is the first case of septic shock required ventilator care and continuous renal replacement therapy due to these organisms in Korea.

Septic Shock due to Unusual Pathogens, Comamonas testosteroni and Acinetobacter guillouiae in an Immune Competent Patient / 대한중환자의학회지

Comamonas testosteroni and Acinetobacter guillouiae are gram-negative bacilli of low virulence that are widely distributed in nature and normal flora. Despite their common occurrence in environments, they rarely cause infectious disease. We experienced a case of septic shock by C. testosterone and A. guillouiae, and isolated them by 16S ribosomal RNA sequencing method from the blood cultures of a previous healthy female during postoperative supportive care. This is the first case of septic shock required ventilator care and continuous renal replacement therapy due to these organisms in Korea.