Delayed Post-Hypoxic Leukoencephalopathy Induced by an Overdose with Fentanyl Patches: A Case Report

Fentanyl intoxication has occasionally been reported since fentanyl patches became available for medical use. Delayed post-hypoxic leukoencephalopathy is a complication of hypoxia. However, its neuropsychiatric symptoms can be delayed, and it can progress to leukoencephalopathy even after full recovery from coma due to acute intoxication. Herein, we report a case of fentanyl intoxication in a 65-year-old man who was presented to the hospital because of unconsciousness for 13 hours after using ten fentanyl patches simultaneously. Initial brain CT findings were non-specific. Twenty days later, delayed neuropathologic symptoms manifested, and MRI showed bilaterally symmetrical, heterogeneous, confluent high signal intensities on T2-weighted/fluid attenuated inversion recovery MRI in the cerebral white matter with diffusion restriction. This was followed by rapid exacerbation of neuropathological symptoms with diffuse severe cerebral atrophy over 1 year.

Brain MRI Findings of the Cri-Du-Chat Syndrome: A Case Report and Summary

Cri-du-chat syndrome is a rare genetic disorder in which the patient presents with a characteristic high-pitched monotonous cry and recurrent aspiration pneumonia, attributed to abnormalities in the larynx, epiglottis, and nervous system. The most prominent brain MRI findings are the presence of pontine and cerebellar hypoplasia, which primarily involve posterior cranial fossa structures. Although atrophy of supratentorial structures were also a common radiological finding, it was considered to be a secondary change due to pontine hypoplasia. Here, we present the case of a three-month-old patient presenting with cri-du-chat at our institution. The patient also showed the presence of prominent pontine hypoplasia similar to previously reported cases; however, contrary to other cases, there was a general delayed myelination of brain instead of decreased myelination of anterior limb of internal capsule. Since the larynx, pons, and cerebellum all originated from similar notochord level, which suggests anomaly in early stage of development, laryngeal, and brain anomaly characteristically observed in the cridu- chat syndrome.

Epithelial-mesenchymal transition in keloid tissue

No abstract available.

Catheter-related Bloodstream Infection due to Lodderomyces elongisporus in a Patient with Lung Cancer

No abstract available.

Selection of Implants in Unilateral Prosthetic Breast Reconstruction and Contralateral Augmentation

BACKGROUND: In breast reconstruction using implants after unilateral mastectomy, it is challenging to create a natural, ptotic contour, and asymmetry is a potential drawback. To achieve breast symmetry and an ideal shape for both breasts, we performed contralateral augmentation in patients undergoing breast reconstruction with implants. METHODS: Patients underwent unilateral mastectomy and 2-stage reconstruction. During the second stage of the procedure, contralateral augmentation mammoplasty was performed. Preoperatively, we obtained the patients’ demographic information, and we then assessed breast volume, the volume and dimensions of the inserted implants, and complications. Breast symmetry was observed by the surgeon and was assessed by measuring the disparity between the final volume of each breast. RESULTS: Contralateral augmentation was performed in 52 cases. When compared to patients who did not undergo a contralateral balancing procedure, patients who received contralateral augmentation were younger, thinner, and had smaller breasts. During implant selection for contralateral augmentation, we chose implants that were approximately 1 cm shorter in width, 1 level lower in height, and 1 or 2 levels lower in projection than the implants used for reconstruction. The postoperative breast contours were symmetric and the final volume discrepancy between each breast, which was measured by 3-dimensional scanning, was acceptable. CONCLUSIONS: We demonstrate that contralateral augmentation can be recommended for patients who perceive their breasts to be small and not beautiful in order to achieve an ideal and beautiful shape for both breasts. Furthermore, this study offers guidelines for selecting the implant that will lead to the optimal aesthetic outcome.

Selection of Implants in Unilateral Prosthetic Breast Reconstruction and Contralateral Augmentation

BACKGROUND: In breast reconstruction using implants after unilateral mastectomy, it is challenging to create a natural, ptotic contour, and asymmetry is a potential drawback. To achieve breast symmetry and an ideal shape for both breasts, we performed contralateral augmentation in patients undergoing breast reconstruction with implants. METHODS: Patients underwent unilateral mastectomy and 2-stage reconstruction. During the second stage of the procedure, contralateral augmentation mammoplasty was performed. Preoperatively, we obtained the patients’ demographic information, and we then assessed breast volume, the volume and dimensions of the inserted implants, and complications. Breast symmetry was observed by the surgeon and was assessed by measuring the disparity between the final volume of each breast. RESULTS: Contralateral augmentation was performed in 52 cases. When compared to patients who did not undergo a contralateral balancing procedure, patients who received contralateral augmentation were younger, thinner, and had smaller breasts. During implant selection for contralateral augmentation, we chose implants that were approximately 1 cm shorter in width, 1 level lower in height, and 1 or 2 levels lower in projection than the implants used for reconstruction. The postoperative breast contours were symmetric and the final volume discrepancy between each breast, which was measured by 3-dimensional scanning, was acceptable. CONCLUSIONS: We demonstrate that contralateral augmentation can be recommended for patients who perceive their breasts to be small and not beautiful in order to achieve an ideal and beautiful shape for both breasts. Furthermore, this study offers guidelines for selecting the implant that will lead to the optimal aesthetic outcome.

Medical Thoracoscopy in Pleural Disease: Experience from a One-Center Study / 결핵및호흡기질환

BACKGROUND: Medical thoracoscopy (MT) is a minimally invasive, endoscopic procedure for exploration of the pleural cavity under conscious sedation and local anesthesia. MT has been performed at the Seoul National University Hospital since February 2014. This paper summarizes the findings and outcomes of MT cases at this hospital. METHODS: Patients who had undergone MT were enrolled in the study. MT was performed by pulmonologists, using both rigid and semi-rigid thoracoscopes. During the procedure, patients were under conscious sedation with fentanyl and midazolam. Medical records were reviewed for clinical data. RESULTS: From February 2014 to January 2016, 50 procedures (47 cases) were performed (diagnostic MT, 26 cases; therapeutic MT, 24 cases). The median age of patients was 66 years (59–73 years), and 38 patients (80.9%) were male. The median procedure duration from initial incision to insertion of the chest tube was 37 minutes. The median doses of fentanyl and midazolam were 50 µg and 5 mg, respectively. All procedures were performed without unexpected events. Of the 26 cases of pleural disease with an unknown cause, 19 were successfully diagnosed using MT. Additionally, diagnostic MT provided clinically useful information in the other six patients. Therapeutic MT was very effective for treatment of malignant pleural effusion or empyema. The median number of days with chest tube drainage was 6 (3 days for diagnostic MT and 8 days for therapeutic MT). CONCLUSION: MT is a useful and necessary procedure for both diagnosis and treatment of pleural diseases.

Effect of Antibiotic Prophylaxis on Early-Onset Pneumonia in Cardiac Arrest Patients Treated with Therapeutic Hypothermia / 대한구급학회지

BACKGROUND: Infectious complications frequently occur after cardiac arrest and may be even more frequent after therapeutic hypothermia. Pneumonia is the most common infectious complication associated with therapeutic hypothermia, and it is unclear whether prophylactic antibiotics administered during this intervention can decrease the development of early-onset pneumonia. We investigated the effect of antibiotic prophylaxis on the development of pneumonia in cardiac arrest patients treated with therapeutic hypothermia. METHODS: We retrospectively reviewed the medical records of patients who were admitted for therapeutic hypothermia after resuscitation for out-of-hospital cardiac arrest between January 2010 and July 2015. Patients who died within the first 72 hours or presented with pneumonia at the time of admission were excluded. Early-onset pneumonia was defined as pneumonia that developed within 5 days of admission. Prophylactic antibiotic therapy was defined as the administration of any parenteral antibiotics within the first 24 hours without any evidence of infection. RESULTS: Of the 128 patients admitted after cardiac arrest, 68 were analyzed and 48 (70.6%) were treated with prophylactic antibiotics within 24 hours. The frequency of early-onset pneumonia was not significantly different between the prophylactic antibiotic group and the control group (29.2% vs 30.0%, respectively, p = 0.945). The most commonly used antibiotic was third-generation cephalosporin, and the class of prophylactic antibiotics did not influence early-onset pneumonia. CONCLUSION: Antibiotic prophylaxis in cardiac arrest patients treated with therapeutic hypothermia did not reduce the frequency of pneumonia.

A patient with Cushing disease lateralizing a pituitary adenoma by inferior petrosal sinus sampling using desmopressin: a case report

A 14-year-old girl was referred for evaluation of the etiology of Cushing syndrome. During the previous 2 years, she had experienced weight gain, secondary amenorrhea, growth retardation, and back pain. Random serum cortisol level, 24-hour urinary free cortisol excretion, and overnight and low-dose dexamethasone suppression tests suggested Cushing syndrome. Midnight adrenocorticotropic hormone (ACTH) level and high-dose dexamethasone suppression test confirmed Cushing disease. Pituitary magnetic resonance imaging was suspicious for microadenoma. To eliminate ectopic ACTH syndrome, and lateralize the pituitary tumor, inferior petrosal sinus sampling (IPSS) was performed by desmopressin use to stimulate ACTH. Finally, the patient was diagnosed with Cushing disease due to ACTH-secreting pituitary microadenoma, lateralized to the left side; subsequently underwent transsphenoidal surgery. Here we report a case of a 14-year-old girl diagnosed with Cushing disease with a pituitary tumor lateralized by IPSS using desmopressin, which is very rare in pediatric Cushing disease.

Male patients presenting with rapidly progressive puberty associated with malignant tumors

In males, precocious puberty (PP) is defined as the development of secondary sexual characteristics before age 9 years. PP is usually idiopathic; though, organic abnormalities including tumors are more frequently found in male patients with PP. However, advanced puberty in male also can be an important clinical manifestation in tumors. We report 2 cases of rapidly progressive puberty in males, each associated with a germ-cell tumor. First, an 11-year-old boy presented with mild fever and weight loss for 1 month. Physical examination revealed a pubertal stage of G3P3 with 10-mL testes. Investigations revealed advanced bone age (16 years) with elevated basal luteinizing hormone and testosterone levels. An anterior mediastinal tumor was identified by chest radiography and computed tomography, and elevated α-fetoprotein (AFP) and β-human chorionic gonadotropin (β-hCG) levels were noted. Histopathologic analysis confirmed a yolk-sac tumor. Second, a 12-year-old boy presented with diplopia, polydipsia, and polyuria for 4 months. Physical examination revealed a pubertal stage of G3P3 with 8-mL testes. Bone age was advanced (16 years) and laboratory tests indicated panhypopituitarism with elevated testosterone level. A mixed germ-cell tumor was diagnosed with elevated AFP and β-hCG levels. Of course, these patients also have other symptoms of suspecting tumors, however, rapidly progressive puberty can be the more earlier screening sign of tumors. Therefore, in male patients with accelerated or advanced puberty, malignancy should be considered, with evaluation of tumor markers. In addition, advanced puberty in male should be recognized more widely as a unique sign of neoplasm.

Effect of Antibiotic Prophylaxis on Early-Onset Pneumonia in Cardiac Arrest Patients Treated with Therapeutic Hypothermia / 대한중환자의학회지

BACKGROUND: Infectious complications frequently occur after cardiac arrest and may be even more frequent after therapeutic hypothermia. Pneumonia is the most common infectious complication associated with therapeutic hypothermia, and it is unclear whether prophylactic antibiotics administered during this intervention can decrease the development of early-onset pneumonia. We investigated the effect of antibiotic prophylaxis on the development of pneumonia in cardiac arrest patients treated with therapeutic hypothermia. METHODS: We retrospectively reviewed the medical records of patients who were admitted for therapeutic hypothermia after resuscitation for out-of-hospital cardiac arrest between January 2010 and July 2015. Patients who died within the first 72 hours or presented with pneumonia at the time of admission were excluded. Early-onset pneumonia was defined as pneumonia that developed within 5 days of admission. Prophylactic antibiotic therapy was defined as the administration of any parenteral antibiotics within the first 24 hours without any evidence of infection. RESULTS: Of the 128 patients admitted after cardiac arrest, 68 were analyzed and 48 (70.6%) were treated with prophylactic antibiotics within 24 hours. The frequency of early-onset pneumonia was not significantly different between the prophylactic antibiotic group and the control group (29.2% vs 30.0%, respectively, p = 0.945). The most commonly used antibiotic was third-generation cephalosporin, and the class of prophylactic antibiotics did not influence early-onset pneumonia. CONCLUSION: Antibiotic prophylaxis in cardiac arrest patients treated with therapeutic hypothermia did not reduce the frequency of pneumonia.

Efficacy of Lactose-free Milk in Korean Adults with Lactose Intolerance / 대한소화기학회지

BACKGROUND/AIMS: Lactose-free milk (LFM) is available for nutrient supply for those with lactose intolerance (LI). However, there are no consistent results of the efficacy of LFM in LI subjects. We aimed to examine the changes of gastrointestinal (GI) symptoms and hydrogen breath test (HBT) values after ingestion of lactose contained milk (LCM) vs. LFM. METHODS: From May 2015 to September 2015, thirty-five healthy adults with history of LCM-induced GI symptoms were recruited at a tertiary hospital. For the diagnosis of LI, HBT with LCM 550 mL (lactose 25 g) was performed every 20 minutes for 3 hours. The test was defined as "positive" when H2 peak exceeded 20 ppm above baseline values (DeltaH2>20 ppm). When the subjects are diagnosed as LI, the second HBT using LFM 550 mL (lactose 0 g) was performed 7 days later. Subjects were asked to complete a questionnaire about the occurrence and severity of GI symptoms. RESULTS: Among a total of 35 subjects, 31 were diagnosed with LI at first visit, and their LCM-related symptoms were abdominal pain (98.6%), borborygmus (96.8%), diarrhea (90.3%), and flatus (87.1%). The DeltaH2 value in subjects taking LCM (103.7+/-66.3 ppm) significantly decreased to 6.3+/-4.9 ppm after ingesting LFM (p<0.0001). There were also significant reduction in total symptom scores and the severity of each symptom when LCM was changed to LFM (p<0.0001). CONCLUSIONS: This is the first report that LFM reduce LCM-related GI symptoms and H2 production in Korean adults. LFM can be an effective alternative for LCM in adults with LI.

Neuro-Behcet's Disease Presenting as Hypertrophic Pachymeningitis

A 25-year-old man presented with blurred vision and chronic headache. His brain MRI revealed bilateral frontal pachymeningeal enhancement with leptomeningeal enhancement. The patient had experienced recurrent oral ulcer and had anterior uveitis and papulopustules skin lesion. We diagnosed him with hypertrophic pachymeningitis (HP) associated with neuro-Behcet's disease (NBD). There have been few reports describing HP in patients with NBD. We report a case of NBD presenting as HP.

Hypotonic hyponatremia by primary polydipsia caused brain death in a 10-year-old boy

Hypotonic hyponatremia by primary polydipsia can cause severe neurologic complications due to cerebral edema. A 10-year-and-4-month-old boy with a psychiatric history of intellectual disability and behavioral disorders who presented with chief complaints of seizure and mental change showed severe hypotonic hyponatremia with low urine osmolality (serum sodium, 101 mmol/L; serum osmolality, 215 mOsm/kg; urine osmolality, 108 mOsm/kg). The patient had been polydipsic for a few months prior, and this had been worse in the previous few days. A diagnosis of hypotonic hyponatremia caused by primary polydipsia was made. The patient was in a coma, and developed respiratory arrest and became brain death shortly after admission, despite the treatment. The initial brain magnetic resonance imaging showed severe brain swelling with tonsillar and uncal herniation, and the patient was declared as brain death. It has been reported that antidiuretic hormone suppression is inadequate in patients with chronic polydipsia, and that this inadequate suppression of antidiuretic hormone is aggravated in patients with acute psychosis. Therefore, hyponatremia by primary polydipsia, although it is rare, can cause serious and life-threatening neurologic complications.

Risk Factors for Postoperative Cardiopulmonary Instability Following Ligation of Patent Ductus Arteriosus in Very Low Birth Weight Infants

PURPOSE: Patent ductus arteriosus (PDA) is common in preterm infants, and about 30% of preterm infants undergo surgical ligation of the PDA. Cardiopulmonary instability, defined as hypotension and respiratory failure after PDA ligation, is reported to occur at a frequency of 40-50%. This study investigated the factors affecting cardiopulmonary instability after PDA ligation in preterm infants. METHODS: The medical records of 45 very low birth weight (VLBW) infants who underwent PDA ligation in the neonatal intensive care unit from January 2009 to December 2013 were analyzed retrospectively. PDA ligation was only performed when medical treatment for hemodynamically significant PDA failed or was contraindicated. The cases were categorized into the hemodynamic instability (n=20) and control (n=25) groups. RESULTS: Patients underwent ligation at the mean age of 14.3+/-13.3 days. There were no significant differences between groups in mortality or weaning from ventilation after PDA ligation. In the hemodynamic instability group, birth weight was significantly lower (P=0.046) and the pre-operation C-reactive protein (CRP) level was significantly higher (P=0.042) than in the control group. The use of high-frequency ventilation was higher in the hemodynamic instability group (P=0.033). There were no differences in use of inotropics, mean airway pressure at ligation, timing of ligation, or PDA size between groups. The birth weight and pre-operation CRP level at the time of ligation remained a significant risk factor for cardiopulmonary instability on multiple logistic regression analysis. CONCLUSION: In VLBW infants, lower birth weight and a higher pre-operation CRP level are related to unstable conditions after PDA ligation.

Effect of Airflow Limitation on Acute Exacerbations in Patients with Destroyed Lungs by Tuberculosis

History of treatment for tuberculosis (TB) is a risk factor for obstructive lung disease. However, it has been unclear whether the clinical characteristics of patients with destroyed lung by TB differ according to the presence or absence of airflow limitation. The objective of the study was to evaluate differences in acute exacerbations and forced expiratory volume in 1 second (FEV1) decline in patients with destroyed lung by TB according to the presence or absence of airflow limitation. We performed a retrospective cohort study and enrolled patients with destroyed lung by TB. The presence of airflow limitation was defined as FEV1/forced vital capacity (FVC) < 0.7. One hundred and fifty-nine patients were enrolled, and 128 (80.5%) had airflow limitation. The proportion of patients who experienced acute exacerbation was higher in patients with airflow limitation compared to those without (89.1 vs. 67.7%, respectively; P = 0.009). The rate of acute exacerbation was higher in patients with airflow limitation (IRR, 1.19; 95% CI, 1.11-1.27). Low body mass index (X vs. X + 1; HR, 0.944; 95% CI, 0.895-0.996) in addition to airflow limitation (HR, 1.634; 95% CI, 1.012-2.638), was an independent risk factor for acute exacerbation. The annual decline of FEV1 was 2 mL in patients with airflow limitation and 36 mL in those without (P < 0.001). In conclusion, the presence of airflow limitation is an independent risk factor for acute exacerbation in patients with the destroyed lung by TB.

Carpal Tunnel Syndrome Associated with Tophaceous Deposition in Flexor Digitorum Tendons

Carpal tunnel syndrome is the most common peripheral entrapment neuropathy. We report on the first Korean case of carpal tunnel syndrome induced by tophaceous deposition in flexor digitorum tendons of a patient with chronic gout. A 63-year-old male suffered from numbness, decreased sensation over both median nerve distribution, and weakness of thenar muscle for 3 years. Physical examinations revealed positive Tinel's sign and Phalen's test and thenar qjmuscle atrophy was found on both hands. In nerve conduction study, there was no action potential of the sensory and motor of the bilateral median nerve. Ultrasonography showed increased cross-sectional area of median nerve due to tophaceous deposition in flexor digitorum tendons in the carpal tunnel. Dual-energy computed tomography showed diffuse multifocal green color coding tophaceous deposition within the carpal tunnel. His neuropathic symptoms improved after injection of triamcinolone into the carpal tunnel and administration of oral medication including non-steroidal anti-inflammatory drugs and colchicine.

Overtube-related Delayed Esophageal Perforation with Mediastinitis / 대한소화기학회지

Overtube provides a conduit for the passage of endoscope into the digestive tract. Esophageal perforation with mediastinitis is a rare overtube-related complication. Until now, no reports have been published regarding the esophageal perforation which developed many months after the original procedure using the overtube. A 56-year-old female visited our hospital complaining of chest pain and back pain that began 14 days ago. The patient underwent esophageal variceal ligation using the overtube 12 months earlier. She was diagnosed with esophageal perforation with mediastinitis which extended to intervertebral and epidural space. The cause of this condition was considered to have been related to the use of overtube. Management of delayed perforation remains controversial. Although surgical management might be the preferred mode of treatment, she underwent local N-butyl 2-cyanoacrylate injection therapy and temporary stent therapy with antibiotics due to high operative risk. Herein, we report a case of overtube-related delayed esophageal perforation with mediastinitis that was successfully treated by nonoperative management.

A Case of Organizing Pneumonia Associated with FOLFIRI Chemotherapy / 결핵및호흡기질환

The combination chemotherapy of irinotecan with 5-fluorouracil and leucovorin (FOLFIRI regimen) was recently proven to be beneficial in patients with advanced colorectal cancer. Pulmonary toxicity is very rare in adverse effects of irinotecan. No case of organizing pneumonia (also known as bronchiolitis obliterans organizing pneumonia) associated with FOLFIRI chemotherapy has been reported. We experienced a case of a 62-year-old man who presented persistent dry cough and progressive dyspnea after receiving chemotherapy with FOLFIRI regimen. After surgical lung biopsy, the patient was diagnosed with FOLFIRI chemotherapy-induced organizing pneumonia which was successfully treated with steroid therapy.

Diagnostic Yield of Bronchial Washing Fluid Analysis for Hemoptysis in Patients with Bronchiectasis

PURPOSE: Bronchiectasis is the main cause of hemoptysis. When patients with bronchiectasis develop hemoptysis, clinicians often perform bronchoscopy and bronchial washing to obtain samples for microbiological and cytological examinations. Bronchial washing fluids were analyzed from patients with bronchiectasis who developed hemoptysis, and the clinical impacts of these analyses were examined. MATERIALS AND METHODS: A retrospective observational study of patients who underwent fiberoptic bronchoscopy for hemoptysis in Seoul National University Bundang Hospital, a university affiliated tertiary referral hospital, between January 2006 and December 2010 were reviewed. Among them, patients who had bronchiectasis confirmed by computed tomography and had no definite cause of hemoptysis other than bronchiectasis were reviewed. The demographic characteristics, bronchoscopy findings, microbiological data, pathology results and clinical courses of these patients were retrospectively reviewed. RESULTS: A total of 130 patients were reviewed. Bacteria, non-tuberculous mycobacteria (NTM), and Mycobacterium tuberculosis were isolated from bronchial washing fluids of 29.5%, 21.3%, and 0.8% patients, respectively. Suspected causal bacteria were isolated only from bronchial washing fluid in 19 patients, but this analysis led to antibiotics change in only one patient. Of the 27 patients in whom NTM were isolated from bronchial washing fluid, none of these patients took anti-NTM medication during the median follow-up period of 505 days. Malignant cells were not identified in none of the patients. CONCLUSION: Bronchial washing is a useful method to identify microorganisms when patients with bronchiectasis develop hemoptysis. However, these results only minimally affect clinical decisions.