A Case of Hypersensitivity Pneumonitis Caused by Methotrexate / 결핵

BACKGROUND: Methotrexate (MTX) has been used to treat a wide range of malignant and benign diseases including osteosarcoma, advanced stage non-Hodgkin's lymphoma, psoriasis, severe rheumatoid arthritis, sarcoidosis, and Wegener's granulomatosis. MTX-induced lung injury occurs in up to 10% of treated patients. Although both acute and chronic presentations have been described, typical manifestation of MTX-induced lung injury is subacute with symptoms usually developing within several months after starting therapy. Nonspecific interstitial pneumonia (NSIP) is the most common histopathologic manifestation of MTX-induced lung disease, while bronchiolitis obliterans organizing pneumonia (BOOP) and diffuse alveolar damage (DAD) are less common. Granuloma formation is reported in 34.7%. In Korea, Two reports of MTX pneumonitis have been published. The one presented with NSIP and the other with DAD. We recently experienced a case of MTX pneumonitis with presentation of hypersensitivity pneumonitis.

Physiologic Changes During Bronchoscopy in Mechanically Ventilated Patients / 결핵

BACKGROUND: Bronchoscopy in patients on mechanical ventilation is being performed much more frequently. However, there is little data on the changes in physiologic parameters and no established mechanical ventilation protocol during bronchoscopy. A decreasing or the removal of positive end-expiratory pressure (PEEP) during bronchoscopy may precipitate severe hypoxemia and/or derecruitment. METHODS: Our standardized mechanical ventilation protocol, without changing the PEEP level, was used during bronchoscopy. The physiological parameters were measured during the bronchoscopic procedure. RESULTS: During bronchoscopy, respiratory acidosis, elevation of peak pressure, elevation of heart rate and auto-PEEP were developed, but were reversible changes. Procedure-related gross barotraumas or other severe complications did not developed. CONCLUSION: No serious complications developed during bronchoscopy under our standardized mechanical ventilation protocol when the PEEP level remained unchanged. The procedure time should be kept to a minimum to decrease the exposure time to undesirable physiological changes.

The Changes of Physiologic Parameters with Time in Steroid treated-Late Acute Respiratory Distress Syndrome Patients / 결핵

BACKGROUND: The mortality from acute respiratory distress syndrome(ARDS) is > 40-50%. Although some prospective trials have failed to demonstrate a survival benefit of steroids in the early stages of ARDS, there are some reports showing some success with steroids in the later stages. This study observed the changes in the physiologic parameters with time in late ARDS patients who were treated with steroids. METHODS: The medical charts of 28 intensive care unit patients(male:female=24:4; mean age 64 years), who had been diagnosed with refractory late ARDS (PaO2/FIO2 < 200) and were treated with corticosteroids from December 1999 to July 2002, were retrospectively reviewed. The patients were divided into two groups: the weaned group(n=14), which included the patients who had been successfully weaned from a ventilator after corticosteroid therapy, and the failed group(n=14), which included the patients who had failed weaning. The physiologic parameters included the PaO2/FIO2 ratio, the positive end-expiratory pressure(PEEP) level, the PaCO2, compliance, the sequential organ failure assessment(SOFA) score, the acute physiologic and the chronic health evaluation(APACHE) II score, and the Murray Lung Injury Score(LIS) in the two groups were compared from the day of mechanical ventilation(Dmv) to 7 days after the corticosteroid therapy. RESULTS: There was no significant difference in the clinical characteristics and the physiologic parameters between the two groups prior to the corticosteroid therapy except for the SOFA score at Dmv(weaned group : 6.6+/-2.5 vs failed group : 8.8+/-2.9, p=0.047) . However, within 7 days after corticosteroid therapy, there was significant improvement in the PaO2/FIO2 ratio, the PEEP level, the PaCO2, the SOFA score, the APACHE II score, and the LIS of the weaned group compared to the failed group. CONCLUSIONS: During corticosteroid therapy in late ARDS, the continuation of corticosteroid therapy should be determined carefully in patients who do not show improvement in their physiologic parameters by day 7.

Clinical Characteristics of the Patients with Mycobacterium avium Complex Pulmonary Disease / 결핵

BACKGROUND: Mycobacterium avium complex(MAC) is the most common respiratory pathogen in nontuberculous mycobacterial pulmonary disease. This study described the clinical characteristics of the patients with pulmonary disease caused by MAC. MATERIALS AND METHODS: The clinical characteristics of 24 patients with pulmonary disease caused by the MAC, who fulfilled the 1997 American Thoracic Society diagnostic criteria for nontuberculous mycobacterial pulmonary disease, were retrospectively analyzed. RESULTS: Fourteen patients(58%) were male and the median age at diagnosis was 61 years(range 46-75). Of the 24 patients, 16(67%) had a M. intracellulare infection, 7(29%) had a M. avium infection and one patient was not identified. Coughing(92%) and sputum(88%) were most frequently observed symptoms. The sputum smear for acid-fast bacilli was positive in 17(71%) patients. Fourteen(58%) patients had the upper lobe cavitary form and 10(42%) patients had the nodular bronchiectatic form. In a comparison between the patients with the upper lobe cavitary form and those with the nodular bronchiectatic form, significant differences were found according to sex(male 86% vs. 20%, p=0.003), smoking history(79% vs. 10%, p=0.008), the presence of an underlying disease(64% vs. 20%, p=0.036), the pulmonary function(% forced vital capacity, median 71% vs. 88%, p=0.022; % forced expiratory volume in one second, median 69% vs. 89%, p=0.051) and bilateral disease at chest radiography(29% vs. 90%, p=0.005). The time from the onset of symptoms to diagnosis was longer in those with the nodular bronchiectatic form(median 72 months, range 8-132) than those with the upper lobe cavitary form(median 22 months, range 6-60) CONCLUSIONS: MAC pulmonary disease occurs in two distinct populations with two distinct clinical presentations. For a correct diagnosis of MAC pulmonary disease, knowledge of the diverse clinical and radiological findings is essential.

Clinical and Radiographic Characteristics of 12 Patients with Mycobacterium abscessus Pulmonary Disease / 결핵

BACKGROUND: Mycobacterium abscessus is the most common respiratory pathogen in rapidly growing mycobacteria and is resistant to all of the first-line antituberculosis drugs. This report describes the clinical and radiographic characteristics in patients with pulmonary disease caused by M. abscessus. MATERIALS AND METHODS: Twelve patients with pulmonary disease caused by M. abscessus who fulfilled the 1997 American Thoracic Society diagnostic criteria for a nontuberculous mycobacterial pulmonary infection were observed over a five-and-a-half year period. The clinical characteristics and chest radiographic findings were analyzed, retrospectively. RESULTS: The patients were predominantly female(11/12, 92%) and nonsmokers(12/12, 100%). Coughing (10/12, 83%), sputum(10/12, 83%) and hemoptysis(10/12, 83%) were the common symptoms and they had prolonged periods from the onset of symptoms to the diagnosis of their disease(median 6.5 years). Eleven (92%) patients had a previous history of being treated for pulmonary tuberculosis. The sputum specimens were acid-fast bacilli smear-positive in all patients. All patients were administered antituberculosis drugs. Six (50%) patients were treated with second-line antituberculosis drugs on account of persistent smear-positive sputum specimens. The chest radiographs showed that reticulonodular opacities(11/12, 92%) were the most common pattern of abnormality, followed by cavitary lesions(5/12, 42%). The computed tomography findings suggested bronchiolitis from the centrilobular nodules with a tree-in-bud appearances(9/10, 90%) and bronchiectasis (9/10, 90%) were the most common, followed by well-defined nodules smaller than 10-mm in diameter(7/10, 70%). CONCLUSIONS: M. abscessus pulmonary disease should be recognized as a cause of chronic mycobacterial lung disease, and respiratory isolates should be assessed carefully.

Two Cases of Collagenous Colitis / 대한소화기내시경학회지

Collagenous colitis was first described by Lindstrom in 1976. Now this disorder is recognized as one of the more common causes of chronic diarrhea of obscure origin. This disorder is described as a disease of colon associated with chronic watery diarrhea and the typical histologic findings of a thickened subepithelial collagenous band. But in korea a few cases have been reported. We had observed a 52-year-old businessman with chronic watery diarrhea without abdominal pain in the past. And then we had reported previously that case. We also recently observed a 42-year-old housewife with chronic watery diarrhea with lower abdominal discomfort for 10 years. Colonoscopy disclosed no gross abnormalities through the entire colon ineluding the terminal ileum but we could find the pronounced thickening of subepithelial collageous band and chronic inflammation in the lamina propria in the histologic examination. We summarized the above two cases of collagenous colitis with a review of literatures.

A Study for The Changing Subsite Distribution of Colorectal Cancer with Age and Sex / 대한소화기내시경학회지

BACKGROUND/AIMS: Changes in subsite distribution of colorectal cancer have been shown in recent years. The carcinoma tend to shift to more proximal colon and this proximal shift is influenced by age and sex. This study was designed to delineate the relationship of age to subsite incidence of colorectal cancer and to define the role of gender in this difference. METHOD: We have analyzed the data by patients with colorectal cancer from 1985 to 1995 for elucidate the relationships between age, sex and prinmry location of colorectal cancer. 749 patients(male 454, female 295) were diagnosed of colorectal cancer performed by colonoscopy and/or sigmoidoeopy were divided into three groups by their location of cancer (Right colon: appendix, ascending colon, hepatic flexure, T-colon proximal 2/3 Left colon: T-colon distal 1/3, splenic flexure, descending colon, sigmoid colon Rectum: rectum). RESULTS: 1) The mean age of all patients was 53.84 +/- 13.11(yr). Mean ages of Right colon, Left colon, and Rectal cancer group were 55.54 +/- 14.12, 55.32 +/- 12.51, 52.22 +/- 13.09(yr), respectively. The mean age of Right colon and Left colon cancer group is significantly older than that of Rectal cancer group (p=0.0040, p=0.0042). 2) Infemale age group over 56, mean age of Right colon cancer group is shown to be 3.35 and 4.82 years older than Left colon cancer group and Rectal cancer group, respectively (p=0.0062, p=0.0053) and Colon cancer tend to develop on more right side according to increase in age. 3) Above correlation was not observed below 55 of both sexes and male age group over 56. 4) No significant differences in histological differentiation and tumor stage were observed among the three groups. 5) The study was conducted to evaluate the difference in the location of colorectal cancer between two following groups; The first group diagnosed from 1985 to 1990 and the second group from 1991 to 1995, yet significant statistical difference was not observed. CONCLUSION: Age increase seems to show correlation with right shifting of colon cancer, and this correlation was most significant in old women age group. This finding suggests unknown factor strongly linked to age and sex might play important role in carcinogenesis of colorectal cancer.