A Case of Recurrent Glucocorticoid-Induced Pheochromocytoma Crisisb during the Treatment of Urticaria / 대한내과학회지

Pheochromocytoma crisis is a life-threatening endocrine emergency. Stimuli that can elicit a pheochromocytoma crisis include anesthesia, tumor manipulation, and several drugs. Rarely, glucocorticoids can induce a pheochromocytoma crisis. Here, we describe the case of a 65-year-old female who developed an adrenergic crisis with blood pressure fluctuations, dizziness, and seizures after receiving glucocorticoids for the treatment of urticaria. The symptoms led us to speculate that a pheochromocytoma was present. We confirmed the diagnosis based on abdominal imaging and biochemical studies. The patient's symptoms improved after surgical removal of the pheochromocytoma.

Neutrophil to Lymphocyte Ratio Predicts Long-Term Clinical Outcomes in Patients with ST-Segment Elevation Myocardial Infarction Undergoing Primary Percutaneous Coronary Intervention

BACKGROUND AND OBJECTIVES: A higher neutrophil to lymphocyte ratio (NLR) has been associated with poor clinical outcomes in various cardiac diseases. However, the clinical availability of NLR in patients with ST-elevation myocardial infarction (STEMI) undergoing primary percutaneous coronary intervention (PCI) has not been known. We evaluated the availability of NLR to predict clinical outcomes in patients with STEMI undergoing primary PCI. SUBJECTS AND METHODS: We analyzed 326 consecutive STEMI patients treated with primary PCI. The patients were divided into tertiles according to NLR: NLR6.53 (n=110). We evaluated the incidence of major adverse cardiac events (MACE), a composite of all causes of death, non-fatal MI, and ischemic stroke at the 12-month follow-up. RESULTS: The high NLR group was associated with a significantly higher rate of 12-month MACE (19.1% vs. 3.7%, p<0.001), 12-month death (18.2% vs. 2.8%, p<0.001), in-hospital MACE (12.7% vs. 2.8%, p=0.010) and in-hospital death (12.7% vs. 1.9%, p=0.003) compared to the low NLR group. In the multivariable model, high NLR was an independent predictor of 12-month MACE {hazard ratio (HR) 3.33 (1.09-10.16), p=0.035} and death {HR 4.10 (1.17-14.46), p=0.028} after adjustment for gender, left ventricular ejection fraction, creatinine clearance, angiographic parameters and factors included in the Thrombolysis in Myocardial Infarction risk score for STEMI. There was a significant gradient of 12-month MACE across the NLR tertiles with a markedly increased MACE hazard in the high NLR group (log rank test p=0.002). CONCLUSION: The NLR is a useful marker to predict 12-month MACE and death in patients with STEMI who have undergone primary PCI.

Successful Percutaneous Coronary Intervention for Acute Coronary Syndrome in a Patient With Severe Hemophilia A

Patients with hemophilia generally have a reduced frequency of coronary artery disease compared to the general population. As advances in the management of hemophilia have increased their life expectancy, the prevalence of coronary artery disease also has increased. However, there are no standard treatment guidelines for coronary artery disease in patients with hemophilia, especially in the field of coronary intervention. We report the case of a patient with severe hemophilia A who presented with acute coronary syndrome and was successfully treated with percutaneous coronary intervention.

Association of P-Wave Dispersion With Paroxysmal Atrial Fibrillation in Patients With Acute Anterior Wall ST Segment Elevation Myocardial Infarction

BACKGROUND AND OBJECTIVES: P-wave dispersion (PWD) is a well-known electrophysiologic parameter of atria which are prone to fibrillation. Although paroxysmal atrial fibrillation (PAF) following an acute myocardial infarction (AMI) is not uncommon, the relationship between PWD and PAF following AMI has not been determined. SUBJECTS AND METHODS: We reviewed the electrocardiograms, recorded on admission and every day during hospitalization, of 144 patients with primary anterior AMIs and measured the P-wave duration. The left atrial diameter and left ventricular ejection fraction (LVEF) were evaluated by echocardiography. RESULTS: PAF occurred in 20 patients. The maximum P-wave duration and PWD were found to be significantly higher in patients with PAF than those without PAF (120.1+/-8.6 vs. 109.2+/-12.2 ms, p<0.001; and 68.5+/-11.9 vs. 48.7+/-9.6 ms, p<0.001, respectively). The minimum P-wave duration was significantly lower in patients with PAF than in patients without PAF (51.6+/-13.3 vs. 60.4+/-11.7 ms, respectively, p=0.003). There was no significant difference in the left atrial diameter between patients with PAF and patients without PAF (37.3+/-4.4 vs. 36.8+/-5.1 mm, respectively p=0.652); however, the LVEF was significantly different in the patients who developed PAF compared to those who did not develop PAF (38.5+/-11.4 vs. 45.1+/-8.7%, respectively, p=0.003). CONCLUSION: The maximum P-wave duration and PWD were significant predictive factors of PAF in patients with anterior wall ST elevation AMI based on univariate analysis. On the basis of multivariate analysis, age was an independent predictive parameter for PAF as well.

Therapeutic Strategy for In-Stent Restenosis Based on the Restenosis Pattern After Drug-Eluting Stent Implantation

BACKGROUND AND OBJECTIVES: The aim of this study was to evaluate the outcomes of repeated percutaneous coronary intervention (PCI) based on the restenosis pattern in drug-eluting stent (DES) failure. SUBJECTS AND METHODS: From April 2003 to March 2006, all 67 patients (67 lesions) at our 3 centers who had DES in-stent restenosis (ISR) were enrolled. The patients were divided into 3 groups: group I had focal edge restenosis, group II had focal body restenosis, and group III had non-focal restenosis. All patients were treated with conventional PCI including plain old balloon angioplasty (POBA), cutting balloon angioplasty (CBA), and repeated DES implantation (Re-DES). Angiographic and clinical one year follow-up results for the 3 groups were evaluated. RESULTS: Sixteen patients were enrolled in group I, 36 in group II, and 15 in group III. Baseline clinical and angiographic characteristics and the proportion of patients in each group receiving each type of treatment strategy were not significantly different among the groups. Within each group, a comparison of angiographic and clinical outcomes for each therapeutic modality revealed that restenosis rates were not statistically different. Although rates of major adverse cardiac events (MACE) were not statistically different between groups I and II, in group III, MACE were 3-fold higher for the POBA (4/4, 100.0%) and CBA (4/4, 100.0%) subgroups than for Re-DES (1/3, 33.3%) (p=0.06), but the differences did not reach statistical significance. CONCLUSION: The present study suggests that treatment of DES ISR should be individualized according to restenosis pattern: any PCI strategy appears appropriate for focal ISR patterns, while Re-DES might be a better choice for non-focal ISR patterns.

Multiple Sequential Complications After Sirolimus-Eluting Stent Implantation: Very Late Stent Thrombosis, Stent Fracture, In-Stent Restenosis, and Peri-Stent Aneurysm

A 55-year-old male patient presented with an acute myocardial infarction. A sirolimus-eluting stent (SES) was implanted in the proximal left anterior descending artery (LAD). Eight months later, there was a newly developed distal LAD lesion. An additional SES was implanted. Twenty-eight months after the index procedure of primary coronary intervention, the electrocardiogram showed ST elevation in the precordial leads and an emergency coronary angiogram showed diffuse stent thrombosis (ST) in the proximal LAD. Thirty-four months after the index procedure, coronary angiography showed a large peri-stent coronary aneurysm in the proximal LAD and focal in-stent restenosis (ISR) at the proximal edge of the distal LAD stent. On fluoroscopy, a fracture was noted in the middle part of the distal SES. A zotarolimus- eluting stent (ZES) was deployed and overlapped the restenosis and fracture sites. Forty months after the index procedure, there were no changes in the size of the aneurysm or in the other stent complications including the fracture and restenosis. At present, the patient has remained asymptomatic for eight months.

Comparison of Triple Anti-Platelet Therapy (Aspirin, Clopidogrel, and Cilostazol) and Double Anti-Platelet Therapy (Aspirin and Clopidogrel) on Platelet Aggregation in Type 2 Diabetic Patients Undergoing Drug-Eluting Stent Implantation

BACKGROUND AND OBJECTIVES: Triple anti-platelet therapy may produce more potent inhibition of platelet aggregation in patients undergoing coronary stent implantation. We tested whether this effect could be maintained in diabetic patients, where platelet reactivity is increased and the risk of stent thrombosis is higher. SUBJECTS AND METHODS: Fifty five type 2 diabetic patients who had undergone drug-eluting stent (DES) implantation and chronic anti-platelet therapy (>1 month) were stratified according to the status of anti-platelet therapy. Platelet aggregation after adenosine diphosphate (ADP; 10 micronmol/L and 20 micronmol/L) stimulation was compared using light transmittance aggregometry between dual (aspirin plus clopidogrel, n=34) and triple therapy (aspirin, clopidogrel plus cilostazol, n=21) groups. RESULTS: The 2 groups had similar clinical and procedural characteristics. Maximal ADP-induced platelet aggregation was significantly lower in the triple therapy group than the dual therapy group (ADP 10 micronmol/L, 37.1+/-15.4 vs. 28.3+/-11.8, p=0.03; ADP 20 micronmol/L, 63.1+/-15.0 vs. 49.1+/-15.1, p=0.01), but there were no differences in diabetic treatment (oral hypoglycemic agent vs. insulin) or diabetic control {hemoglobin Alc (HbA1c)7}. CONCLUSION: Triple anti-platelet therapy showed more potent inhibition of maximal ADP induced platelet aggregation in type 2 diabetic patients receiving chronic anti-platelet therapy. This finding suggests that triple antiplatelet therapy may be more effective in preventing thrombotic complications after DES implantation in type 2 diabetic patients.

Huge Aneurysm of the Sinus of Valsalva Compressing the Left Atrium

Sinus of Valsalva aneurysms are rare cardiac anomalies. They can be congenital or acquired, and mainly involve the right or non-coronary sinuses. Unruptured aneurysms are usually asymptomatic unless they compress other structures or produce thrombi. A sinus of Valsalva aneurysm can also produce myocardial infarction through thrombus formation secondary to the turbulent flow in the Valsalva aneurysm. We report a case of a huge sinus of Valsalva aneurysm involving the noncoronary sinus, which was diagnosed as the presumed source of acute myocardial infarction.

Quinidine-Induced QTc Interval Prolongation and Gender Differences in Healthy Korean Subjects

BACKGROUND AND OBJECTIVES: Drug-induced electrocardiographic QT interval prolongation is associated with the occurrence of a potentially lethal form of polymorphic ventricular tachycardia, termed 'torsades de pointes' (TdP). Women are at greater risk for the development of drug-induced TdP. To determine whether this may be the result of gender-specific differences in the effect of quinidine on cardiac repolarization, we compared the degree of quinidine-induced QT interval lengthening in young, healthy volunteers. SUBJECTS AND METHODS: Twelve women and 12 men each received a single intravenous dose of quinidine (4 mg/kg) or placebo in a single-blinded, randomized crossover trial. Total plasma concentrations of quinidine were measured, and QT and corrected QT intervals were analyzed. RESULTS: As expected, the mean QTc interval at baseline was longer for women than for men (443.6+/-26.9 vs 402.1+/-31.3 msec, respectively, p=0.037). The mean value of the maximal DeltaQTc after quinidine infusion was higher in women (134.4+/-46.4 vs 117.5+/-37.7 msec, respectively, p=0.029), and the mean value of the minimal DeltaQTc for 1 hour after quinidine infusion was also higher in the female group (47.6+/-15.7 vs 83.7+/-25.4 msec, p=0.034). However, there were no significant differences in the time courses of the changes in the quinidine-induced QTc and DeltaQTc interval between the two groups (p=0.092, and p=0.305, respectively). CONCLUSION: Quinidine causes greater QT prolongation in women at equivalent serum concentrations. This difference may contribute to the greater incidence of drug-induced TdP observed in women taking quinidine, and has implications for other cardiac and noncardiac drugs that prolong the QTc interval.

A Case of Acute Respiratory Distress Syndrome Caused By Zinc Fume Inhalation / 결핵및호흡기질환

The Inhalation of certain freshly formed metal oxides can cause metal fume fever, which is an acute, self-limiting, flu-like illness. The most common cause of this syndrome is the inhalation of zinc oxide. The inhalation of zinc oxide can lead to tracheobronchiolitis, chemical pulmonary edema or to respiratory failure and acute respiratory distress syndrome(ARDS). We encountered a 43-years-old man who developed severe dyspnea after inhaling of zinc oxide while working for 5 hours in a closed space. He was diagnosed with ARDS and was treated successfully with glucocorticoid. We report a case of ARDS caused by the inhalation of zinc fumes.

A case of primary esophageal T-cell malignant lymphoma / 대한내과학회지

Gastrointestinal tract (GIT) lymphomas usually originate from B-lymphocytes but rarely from T-lymphocytes. The stomach is the most common site for extranodal GIT lymphoma but the esophagus is a rare site. In addition, a primary esophageal T-cell lymphoma is an uncommon disorder. We encountered a case of a primary esophageal T-cell lymphoma in a 60-year-old man, who had swallowing difficulties and multiple ulcers in the upper and lower esophageal mucosa on gastroscopy. Immunohistochemical staining for the biopsy material from the multiple esophageal ulcers tested positive for LCA and CD45RO (pan T-cell marker) and negative for cytokeratin and CD20 reactivity, respectively. No other abnormal lesions were observed on a computed tomography scan of the neck, chest, abdomen and pelvis. After six cycles of combination chemotherapy with cyclophosphamide, adriamycin, vincristin, prednisolone, etoposide and gemcitabine, the multiple esophageal ulcers had completely disappeared suggesting a complete clinical response. We report this case with a review of the relevant literature.

Association between Aortic Valve Sclerosis and Risk Factors of Coronary Artery Disease in Patients with Suspected Coronary Artery Disease

BACKGROUND AND OBJECTIVES: Aortic valve sclerosis (AVS) is often considered to be benign and it is also considered to be a manifestation of generalized atherosclerosis that involves the aortic valve. However, it is associated with high cardiovascular morbidity and mortality in a population-based study. This study was performed to evaluate the significance of AVS in patients with suspected coronary artery disease (CAD). SUBJECTS AND METHODS: Patients with AVS (AVS group, n=111) and patients with normal aortic valves (control group, n=99) who underwent coronary angiography (CAG) between May, 2004 and June, 2004 were enrolled in this study. We compared the CAG findings and the CAD risk factors in both groups, and we evaluated the diagnostic value of AVS for predicting CAD. We also performed multivariate logistic regression analysis for the risk factors, including AVS, of CAD. RESULTS: This study showed that AVS is an independent echocardiographic predictor of significant CAD in the patients with suspected CAD (OR=2.55, 95% CI: 1.25 to 5.17, p<0.001). The other independent predictors include the male gender and hypertension. AVS has a relatively high positive predictive value (75.7%) and predictive accuracy (65.2%) for the patients with suspected CAD. CONCLUSION: The recognition of AVS on transthoracic echocardiography should alert the physicians to the possibility of significant underlying CAD and further evaluation is indicated, even though angiographic documentation might not be available.