IgG4-Related Lung Disease without Elevation of Serum IgG4 Level: A Case Report / 결핵및호흡기질환

Since IgG4-related pancreatitis was first reported in 2001, IgG4-related disease has been identified in other organs such as salivary gland, gallbladder, thyroid, retroperitoneum and kidney; but lung invasion is rare. A 63-year-old man presented with hemoptysis at the pulmonary clinic and chest computed tomography revealed about 4.1 cm irregular shaped mass with spiculated margin at the left upper lobe. Despite no elevation of serum IgG4 level, he was finally diagnosed as IgG4-related lung disease by transthoracic needle biopsy. After treatment with oral glucocorticoids, hemoptysis disappeared and the size of lung mass was decreased.

Risk Factors for Mechanical Ventilation in Patients with Scrub Typhus Admitted to Intensive Care Unit at a University Hospital / 결핵및호흡기질환

BACKGROUND: The purpose of this study was to evaluate the risk factors for mechanical ventilation in the patients with scrub typhus admitted to intensive care unit (ICU) at a university hospital. METHODS: We retrospectively selected and analyzed clinical data from the medical records of 70 patients (32 men, 38 women) admitted to the ICU with scrub typhus between 2004 and 2014. The patients had a mean+/-standard deviation age of 71.2+/-11.1 years and were evaluated in two groups: those who had been treated with mechanical ventilation (the MV group, n=19) and those who had not (the non-MV group, n=51). Mean ages of the MV group and the non-MV group were 71.2+/-8.3 years and 71.2+/-11.1 years, respectively. RESULTS: Significant differences between the two groups were observed with respect to acute respiratory failure (p=0.008), Acute Physiology and Chronic Health Evaluation (APACHE) II score (p=0.015), Sequential Organ Failure Assessment (SOFA) score (p=0.013), death (p=0.014), and ICU duration (p<0.01). Multivariate analysis indicated that the following factors were significantly associated with mechanical ventilation: acute respiratory failure (p=0.011), SOFA score (p=0.005), APACHE II score (p=0.011), platelet count (p=0.009), and lactate dehydrogenase (LDH) (p=0.011). CONCLUSION: Thus, five factors-acute respiratory failure, SOFA score, APACHE II score, platelet count, and LDH-can be the meaningful indicators for mechanical ventilation for the patients with scrub typhus admitted to ICU.

Agranulocytosis Induced by Ethambutol in a Patient with Pulmonary Tuberculosis / 결핵및호흡기질환

We report a case of agranulocytosis caused by ethambutol in a 79-year-old man with pulmonary tuberculosis. He was referred for fever and skin rash developed on 21th day after antituberculosis drugs (isoniazid, rifampicin, ethambutol, and pyrazinamide) intake. Complete blood count at the time of diagnosis of pulmonary tuberculosis was normal. On the seventh admission day, agranulocytosis was developed with absolute neutrophil count of 70/microL. We discontinued all antituberculosis drugs, and then treated with granulocyte colony-stimulating factor. Three days later, the number of white blood cell returned to normal. We administered isoniazid, pyrazinamide, and ethambutol in order with an interval. However, fever and skin rash developed again when adding ethambutol, so we discontinued ethambutol. After these symptoms disappeared, we added rifampicin and ethambutol in order with an interval. However after administering ethambutol, neutropenia developed, so we discontinued ethambutol again. He was cured with isoniazid, rifampicin, and pyrazinamide for 9 months.

Diffuse Alveolar Hemorrhage Confirmed by Bronchoalveolar Lavage in a Patient with Hemoptysis after Sildenafil Use for Erectile Dysfunction / 대한구급학회지

A 81-year-old man was referred for respiratory failure by emergency medical technicians. He admitted at intensive care unit for ventilator treatment. Several hours before admission, he took sildenafil 100 mg for erectile dysfunction without prescription. The episodes of hemoptysis occurred several hours later. Computed tomography revealed multifocal diffuse ground-glass attenuation in both lungs. And the more we performed bronchoalveolar lavage, the more the color of it was turned into red. We treated him with empirical antibiotics and tranexamic acid, and hemoptysis was stopped in one day after admission. But in the 5th admission day, he died from sepsis combined with pneumonia caused by Acinetobacter baumannii abruptly.

Diffuse Alveolar Hemorrhage Confirmed by Bronchoalveolar Lavage in a Patient with Hemoptysis after Sildenafil Use for Erectile Dysfunction / 대한중환자의학회지

A 81-year-old man was referred for respiratory failure by emergency medical technicians. He admitted at intensive care unit for ventilator treatment. Several hours before admission, he took sildenafil 100 mg for erectile dysfunction without prescription. The episodes of hemoptysis occurred several hours later. Computed tomography revealed multifocal diffuse ground-glass attenuation in both lungs. And the more we performed bronchoalveolar lavage, the more the color of it was turned into red. We treated him with empirical antibiotics and tranexamic acid, and hemoptysis was stopped in one day after admission. But in the 5th admission day, he died from sepsis combined with pneumonia caused by Acinetobacter baumannii abruptly.

Issues on Safety of Long-Acting Muscarinic Antagonist / 결핵및호흡기질환

The prevention of and the controlling of symptoms, reductions in the frequency of exacerbations, and disease severity are central to the pharmacologic therapy of chronic obstructive pulmonary disease (COPD). COPD patients are inclined to be older, have more comorbidities, and use polypharmacy as a result. Long-acting inhaled muscarinic antagonists (LAMAs) is a preferred treatment modality. However, the cardiovascular (CV) safety of anti-cholinergics, including LAMA, has been an issue. In contrast, the results of the UPLIFT trial and a pooled analysis of data from 30 trials of tiotropium illustrates the association of tiotropium with reductions in the risk of all cause mortality, CV mortality and CV events. And, the UPLIFT trial provides clues regarding the additive advantages of tiotropium in COPD patients who already are using long-acting inhaled beta2 agonists and inhaled corticosteroids. Following the contribution of tiotropium as a first LAMA, new LAMAs such as aclidinium and glycopyrrolate (NVA-237) seem to be emerging.

Clinical Characteristics and Prognosis of Lung Cancer Patients Admitted to the Medical Intensive Care Unit at a University Hospital / 결핵및호흡기질환

BACKGROUND: The management of patients with lung cancer has improved recently, and many of them will require admission to the medical intensive care unit (MICU). The aim of this study was to examine the clinical characteristics and to identify risk factors for mortality in patients with lung cancer admitted to the MICU. METHODS: We conducted retrospective analysis on 88 patients with lung cancer admitted to the MICU between April 2004 and March 2008. RESULTS: Of the 88 patients (mean age, 66 years), 71 patients (80.7%) had non-small cell lung cancer and 17 patients (19.3%) had small cell lung cancer. Distant metastasis were present in 79 patients (89.8%). The main reasons for MICU admission were acute respiratory failure (77.3%), sepsis (11.4%), and central nervous system dysfunction (4.5%). Mechanical ventilation was used in 54 patients (61.4%). Acute Physiology and Chronic Health Evaluation (APACHE) II score, length of MICU stay, need for mechanical ventilation, source of MICU admission were correlated with MICU mortality. The type of lung cancer and metastasis were not predictive factors of death in MICU. CONCLUSION: Most common reason for ICU admission was acute respiratory failure. Mortality rate of lung cancer patients admitted to the MICU was 65.9%. APACHE II score, length of ICU stay, need for mechanical ventilation, source of MICU admission were predicted factors of death in the MICU.

Clinical Characteristics and Prognosis of Elderly Patients Receiving Prolonged Mechanical Ventilation in the Medical Intensive Care Unit at a University Hospital / 결핵및호흡기질환

BACKGROUND: As the number of older-aged people increases, the number of elderly patients who receive critical care services is expected to increase substantially. The objective of this study was to examine the clinical characteristics and outcomes of elderly patients who receive mechanical ventilation for more than 30 days in the medical intensive care unit (MICU) at a university hospital. METHODS: We retrospectively examined forty-one elderly patients (> or =65 years old) who were receiving mechanical ventilation, from April 2004 to March 2007, for periods exceeding 30 days at the MICU at Eulji University Hospital. RESULTS: The MICU and hospitalmortality rate were 60.9% and 65.9%, respectively. The mean length of the ICU stay was 57.5 days and the mean duration of mechanical ventilation was 49.3 days. The most common reason for MICU admission was acute respiratory failure (73.2%), followed by sepsis (12.2%), neurological problems (9.8%), and gastrointestinal bleeding (4.9%). The Acute Physiology and Chronic Health Evaluation (APACHE) II scores were higher for the nonsurvivors than for the survivors (28.0 vs. 25.0, respectively, p=0.03). The nonsurvivors received more red blood cell (RBC) transfusions during their ICU stay than did the survivors (84.0% vs. 43.8%, respectively p=0.007). The factors associated with hospital death were the APACHE II score and if the patient had received a RBC transfusion. CONCLUSION: The APACHE II score and a RBC transfusion were predictors of increased hospital mortality for the elderly patients who were on prolonged mechanical ventilation. These predictors may assist physicians to make clinical decisions for this patient population.

A Case of Spontaneous Pneumomediatsinum during Taekwondo / 결핵및호흡기질환

Spontaneous pneumomediastinum is defined as a clinical syndrome thatos characterized by the presence of air in the mediastinal space, which is not due to an old previous injury or surgery. The condition is caused by a sustained increase in the intraalveolar and intrabronchial pressure with extravasated air dissecting along the perivascular spaces of the mediastinum. This is an uncommon complication of sports activity. The most common symptom is chest pain. This diagnosis should be considered for younger people who present with pleuritic chest pain or dyspnea and a characteristic crackling feel (known as subcutaneous crepitation) when touching of the skin covering the chest wall or neck, and they look otherwise well with normal vital signs. Usually no treatment is required, but the mediastinal air will be absorbed faster if the patient inspires high concentrations of oxygen. We present here a case of spontaneous pneumomediastinum that occurred during a Taekwondo match, along with a review of the relevant literature.

A Case of Scrub Typhus Complicating Subdural Hematoma

Scrub typhus is an acute febrile illness caused by Orientia tsutsugamushi and manifested with fever, skin rash, myalgia, and hepatitis etc. Most of patients improve with antibiotics such as doxycycline. The spectrum of the clinical severity ranges from mild to severe with fatal complication such as meningoencephalitis, pneumonitis, myocarditis. We report a case of a 72-year-old man with scrub typhus complicating subdural hematoma.

A Case of Scrub Typhus Complicating Subdural Hematoma

Scrub typhus is an acute febrile illness caused by Orientia tsutsugamushi and manifested with fever, skin rash, myalgia, and hepatitis etc. Most of patients improve with antibiotics such as doxycycline. The spectrum of the clinical severity ranges from mild to severe with fatal complication such as meningoencephalitis, pneumonitis, myocarditis. We report a case of a 72-year-old man with scrub typhus complicating subdural hematoma.

The Role of FEV6 in the Diagnosis of Obstructive Airway Disease for the Old Age

BACKGROUND: The most widely used pulmonary function test is spirometry. It is a relatively simple and noninvasive test that measures the volume of air expelled from fully inflated lungs. However, spirometry is an effort-dependent test that requires careful instruction and the full cooperation of the test subject. Because the old patients have relatively longer expiration time than the young patients, it is difficult for both old age and technician to fulfill the end of test criteria for forced vital capacity (FVC) maneuver. In the present study, we aimed to investigate whether forced expiratory volume in six seconds (FEV6) could be utilized in place of FVC in the detection of airway obstruction for the old age. METHODS: Total 353 old age (> or =65years) were enrolled in this study and performed spirometry. Subjects were divided into two groups by FEV1/FVC as the gold standard for diagnosing obstructive airway disease; Group I: 132 patients with FEV1/FVC> or =70% , Group II: 221 patients with FEV1/FVC<70% The relationship between FVC and FEV6 values were analyzed in both groups and differences between the groups were investigated. RESULTS: The mean difference of FVC and FEV6 values (FVC-FEV6) was 138.4+/-23.0 mL (5.06+/-2.86%). This difference was found to be higher in group II (189.4+/-162.5 mL, 7.0+/-5.4%) than group I (52.9+/-47.3 mL, 1.9+/-1.5%). When FEV1/FVC is taken as the gold standard, FEV1/FEV6 had negative predictive value of 87.4% and a sensitivity of 91.4% in the detection of obstructive airway disease. Conclusion: FEV6 was a relative good candidate for parameter in the detection of airway obstruction in the old age for whom it is difficult to fulfill acceptable FVC maneuver. However, additional researches are needed to determine the usefulness of FEV6 in detecting obstructive airway disease of old age.

The Correlation between the Radiological Changes and the Level of Transforming Growth Factor-beta1 in Patients with Pulmonary Tuberculosis / 결핵및호흡기질환

BACKGROUND: Pulmonary tuberculosis is frequently accompanied with complications such as bronchiectasis, cavities, fibrosis and a deterioration of the lung function. However, there is little information available on the pathogenesis of these complications in pulmonary tuberculosis. Among the many factors involving in tissue remodeling, transforming growth factor-beta1 (TGF-beta1) is a potent stimulus of the extracellular matrix fomation and a mediator of potential relevance for airway wall remodeling. Therefore, this study examined the relationship between the radiological changes and the TGF-beta1 level in patients with pulmonary tuberculosis. METHODS: Serum and bronchoalveolar lavage fluid (BALF) were collected from total of 35 patients before treating them for active pulmonary tuberculosis, and the TGF-beta1 levels were measured using an enzyme-linked immunosorbent assay (ELISA). The BALF levels were recalculated as the epithelial lining fluid (ELF) levels using the albumin method. pulmonary function test (PFT) and high resolution computed tomography (HRCT) were performed before and after treatment. RESULTS: There was a strong correlation between the serum TGF-beta1 level and the presence of cavities (r=0.404, p=0.006), even though the BAL TGF-beta1 level showed a weak correlation with complications. In addition, there was no correlation between the TGF-beta1 levels before treatment and the changes in the PFT and HRCT during treatment. CONCLUSION: There is a correlation between the serum TGF-beta1 level and cavity formation in pulmonary tuberculosis before treatment. However, further study will be needed to confirm this.

A Case of Pellagra Induced by Isoniazid during Treatment of Pulmonary Tuberculosis / 결핵및호흡기질환

A Case of Pellagra Induced by Isoniazid during Treatment of Pulmonary Tuberculosis Pellagra is a disease caused by a deficiency of nicotinic acid or niacin. It is mostly found among people eating corn-based diets in parts of China, Africa and India. It is also induced by drugs, such as isoniazid or 5-fluorouracil. Isoniazid inhibits the conversion of tryptophan to niacin and may induce pellagra, particularly in poorly nourished patients. Pellagra should be suspected whenever tuberculous patients under the treatment with isoniazid develop mental, neurological or gastrointestinal symptoms, even in the absence of typical skin changes. Herein, our experienced of a case of pellagra induced by isoniazid during treatment of pulmonary tuberculosis is reported. The patient was referred due to a skin rash and drowsy mental status. Her skin lesion developed during treatment for pulmonary tuberculosis. Her symptoms were improved after discontinuation of antituberculous agents and on the administration of nicotinamide.

Lesion Mimicking Lung Tumor / 결핵및호흡기질환

A 75 year old woman was admitted for evaluation of right lung mass. She was not a smoker. She had been diagnosed as uterine prolapse and during preoperative assessment a lung mass was found incidentally on simple chest X-ray. On chest CT scan, 3.5x2 cm sized homogeneous mass was located in the anterior segment of right upper lobe and there were multiple calcified lymph nodes in both hilum and mediastinal area. We performed diagnostic bronchoscopy, but no definite endobronchial mass was found. Next we did CT guided percutaneous fine needle aspiration biopsy. On microscopy, sulfur granules consisting of multiple granular basophilic centers with hyaline projection of branching filaments were noted. From this finding we made a diagnosis of pulmonary actinomycosis.

A case of ribostamycin-induced anaphylaxis / 대한내과학회지

Anaphylaxis is a life-threatening, systemic reaction manifested by urticaria, angioedema, bronchospasm, syncope and hypotension, which occurs after the exposure to specific antigen such as antibiotics, aspirin, nonsteroidal antiinflammatory drugs, foods, bee sting, or exercise. A 33-year-old woman suffering from anaphylactoid attack after intramuscular administration of ribostamycin at private clinic, was visited to our emergency room and admitted. She had allergic rhinitis and her 8-year-old daughter had atopic dermatitis. She had three previous intramuscular administrations of ribostamycin at every three weeks due to recurrent pelvic inflammatory disease. At third time of ribostamycin administration, she had experienced generalized pruritus, flushing and shortness of breath but these symptoms were resolved spontaneously without medication. Therefore, she didn't notice to attending physician. During the fourth administration of ribostamycin, she developed generalized urticaria and angioedema with dyspnea, dizziness, and severe hypotension. We experienced a case of ribostamycin-induced anaphylaxis, which is rarely mentioned in published articles. We performed a skin prick test and an intradermal test to ribostamycin, which were positive, and report a case of ribostamycin-induced anaphyalxis.

A Case of Primary Leiomyosarcoma with Prominent Osteoclast-like Giant Cell of Lung with Cardiac Invasion / 결핵및호흡기질환

The incidence of a pulmonary leiomyosarcoma as a primary lung tumor is quite rare. We report a case of primary leiomyosarcoma with a cardiac invasion in a 76 year old man. He was admitted due to left anterior chest wall pain for one month. Chest computed tomography showed a 9x8x10cm sized , large round mass in the left upper and lower lobes, and an amorphous low density lesion within the left atrium. Chest magnetic resonance imaging showed a large round mass in the left upper and lower lobes with growth into the left atrium. A diagnosis of leiomyosarcoma with prominent osteoclast-like giant cells was made based on the microscopic and immunohistochemical findings of a permanent specimen by explothoracotomy. The pathologic features of the tumor showed round mononuclear hyperchromatic cells and multinucleated giant cells that resembled osteoclasts. The immunohistochemical staining showed that the giant cells are positive for CD68 but negative for the muscle markers while the round cells were positive for the muscle marker. The patient refused further treatment and died after two months.

Immediate Effect of Hemodialysis on Pulmonary Function and Bronchodilator Response in Patients with Chronic Renal Failure / 결핵

BACKGROUND: We hypothesized that there was a relationship between body weight change and bronchodilator response (BDR) in patients with chronic renal failure (CRF) on hemodialysis (HD). Several mechanisms such as pulmonary edema due to water retention or increased permeability of alveolar capillary may play a important role in pulmonary function impairment and bronchial hyperresponsiveness in patients with CRF on HD. But, no studies have been published concerning BDR in patients with CRF on HD. This study was aimed to know the immediate effect of hemodialysis on pulmonary function and BDR in patients with CRF on HD. METHODS: This study included 30 patients with CRF on HD. We collected data including age, sex, height, pretibial and pedal pitting edema, interdialysis weight gain, postdialysis weight loss , underlying diseases, duration of HD, FEV1, FVC, FEV1/FVC, and BDR before and after HD. RESULTS: Interdialysis weight gain of the patients was 3.4 +/- 1.0 kg, and postdialysis weight loss was 3.2 +/- 0.7 kg. Before HD, FEV1, FVC, and FEV1/FVC of the patients were 89 +/- 22%, 86 +/- 19% of predicted, and 87 +/- 10 %. After bronchodilator inhalation, these parameters were changed to 95 +/- 22%, 90 +/- 19% of predicted, and 88 +/- 9% respectively. BDR was positive in 15 patients. After HD, FEV1, FVC, and FEV1/FVC of the patients were 100 +/- 23%, 94 +/- 18% of predicted, and 88 +/- 11%. After bronchodilator inhalation, these parameters were changed to 102 +/- 23%, 96 +/- 18% of predicted, and 89 +/- 8% respectively. BDR was positive in 9 patients. CONCLUSION: First, HD increases FEV1, FVC, and FEV1/FVC but little affects BDR. Second, there is no correlation between postdialysis weight loss and increases in FEV1, FVC, and FEV1/FVC after HD. Third, there is also no correlation not only between interdialysis weight gain and BDR before HD but between postdialysis weight loss and BDR after HD.

A Pilot Study of Bone Mineral Density in Men with Chronic Obstructive Pulmonary Disease / 결핵

BACKGROUND: Patients with chronic obstructive pulmonary disease (COPD) are at increased risk for osteoporosis, which has implications for mobility and even mortality. The goal of this pilot study was to evaluate bone mineral density (BMD) and risk factors for osteoporosis in a limited number of men with COPD. METHODS: We checked BMD, FEV1(% of predicted) and investigated risk factors for osteoporosis in 44 male patients with COPD who visited our hospital from January to August 2002. RESULTS: Mean(+/-) age was 69+/-9 yrs, body mass index(BMI) 21+/- 3 kg/m2, FEV1 50+/- 18% of predicted, lumbar spine T-score -3.0+/- 1.2, lumbar spine Z-score -2.0+/-1.2, and lumbar spine BMD 0.76 +/-0.13 g/cm2. Osteoporosis(T-score below -2.5) was present in 27 patients(61.4%) and osteopenia(T-scorebetween -1 and -2.5) in 17(38.6%). None of the patients had normal BMD. There was no relationshipbetween BMD and FEV1(% of predicted). There were significant differences in smoking, alcohol consumption, exercise, cumulative steroid dose, BMI and BMD among the three groups according to FEV1(% of predicted) (group1 : > or =65%, group2 : 50-64%, group3 : < or =49%), except age. However, there were no significant differences in these variables between the osteopenia and osteoporosis groups, except BMI. Linear Regression(Stepwise) analysis showed that lumbar BMD was correlated with BMI & exercise. CONCLUSION: BMD is significantly reduced in men with COPD. There was no relationship between BMD and pulmonary function.

A Case of Primary Malignant Fibrous Histiocytoma of the Diaphragm / 결핵

A malignant fibrous histiocytoma (MFH) is a major subset of soft tissue sarcomas, which occurs principally on the extremities or in the retroperitoneum, as well as on the head and neck of elderly patient. However, it is an extremely rare event when a MFH occurs primarily in the diaphragm of a young people. A 25-year-old woman visited our hospital complaining of right chest pain. The chest X-ray showed a diaphragmatic mass. An exploratory thoracotomic biopsy revealed a primary MFH of the diaphragm. The patient was treated with combined chemotherapy consisting of ifosfamide and doxorubicin. A partial response was seen after 6 cycles of chemotherapy. However, she died of brain metastasis 12 months after the diagnosis.