A Case of Chylothorax in an Adult Patient with Down Syndrome Developed after Mechanical Ventilation / 대한내과학회지

Chylothorax is the accumulation of chyle-containing lymphatic fluid within the pleural space. It is mainly caused by injury or obstruction of the thoracic duct due to neoplasm or trauma. There have been several reports of chylothorax associated with chromosomal anomaly such as Down syndrome. Most cases are congenital, and development of chylothorax in an adult with Down syndrome is rare. Here, we report a case of chylothorax in an adult with Down syndrome who had been treated with mechanical ventilation. A 31-year-old woman with Down syndrome was admitted with urosepsis. She was treated with mechanical ventilation due to severe respiratory acidosis. Four days after mechanical ventilation, she developed unilateral pleural effusion, and analysis indicated chylothorax. After conservative treatment, including fasting and total parenteral nutritional support, the chylous formation completely disappeared.

Risk Factors and the Clinical Course of Acute Kidney Injury in Patients with a Femoral Fracture / 대한내과학회지

BACKGROUND/AIMS: Femoral fracture occurs most often in elderly patients and is highly associated with medical problems such as acute kidney injury (AKI); however no reports of AKI in femoral fracture patients have been published. This study was performed to identify risk factors and the clinical course of AKI in patients with femoral fracture. METHODS: We retrospectively evaluated the medical records of 110 patients with femoral fracture between November 2006 and December 2011 at Uijeongbu St. Mary's Hospital. We investigated the incidence and clinical course of AKI in femoral fracture patients and compared the clinical findings between AKI and normal kidney function (NKF) groups. RESULTS: Of the 110 femoral fracture patients, AKI was observed in 19 (17.3%). The peak serum creatinine level in patients with AKI was 2.59 +/- 1.57 mg/dL. Two of 19 patients with AKI died and two progressed to chronic kidney disease. When compared to the NKF group, the AKI group had a higher incidence of elevated lactate dehydrogenase (LDH) (63.2% vs. 34.1%, p = 0.020), erythrocyte sedimentation rate (ESR) (31.6% vs. 6.6%, p = 0.008), and C-reactive protein (57.9% vs. 46.2%, p = 0.042). The AKI group also had a longer hospitalization duration, and more patients were prescribed an angiotensin-converting-enzyme (ACE) inhibitor than in the NKF group. Multivariate analysis demonstrated elevated LDH, ESR and ACE inhibitor prescriptions as independent risk factors for AKI in patients with a femoral fracture. CONCLUSIONS: The incidence of AKI in patients with a femoral fracture was 17.3%, and AKI was associated with a longer clinical course. We recommend monitoring of laboratory findings and medications and early management to reduce the morbidity of patients with AKI.

An Unusual Cause of Left Brachiocephalic Vein Occlusion: Extrinsic Compression by the Aortic Arch in a Hemodialysis Patient / 대한내과학회지

The most common cause of central venous obstruction including left braciocephalic vein is intrinsic stenosis associated with a previous central venous catheter or other devices. Occasionally, patients with no history of central venous catheterization present with left brachiocephalic vein occlusion. This occurs as a result of extrinsic compression of the brachiocephalic vein by adjacent vascular structures, especially the aortic arch and its branches. Here, we report a case of left brachiocephalic vein compression caused by a tortuous, ectatic aortic arch in a patient with no history of central vein catheterization. To our knowledge, this is the first report of extrinsic compression of the brachiocephalic vein by the aortic arch in Korea.

A Case of Adipsic Hypernatremia Associated with Anomalous Corpus Callosum in Adult with Mental Retardation

Adipsic hypernatremia cause chronic hyperosmolality and hypernatremia through a combination of impaired thirst and osmotically stimulated antidiuretic hormone secretion. This syndrome can be grouped together as disorders of osmoreceptor dysfunction due to the various degrees of osmoreceptor destruction related with different types of intracranial lesions around the anterior hypothalamus, consistent with the location of primary osmoreceptor cells. Adipsic hypernatremia, associated with developmental disorder of corpus callosum, is very rare. Most cases are diagnosed at infancy and early childhood; the replacement of desmopressin is necessary. Herein, we report adipsic hypernatremia associated with anomalous corpus callosum in adult with mental retardation; they were treated with only free water without desmopressin.

Renal artery thrombosis secondary to sepsis-induced disseminated intravascular coagulation in acute pyelonephritis

There are some reports of renal vein thrombosis associated with acute pyelonephritis, but a case of renal artery thrombosis in acute pyelonephritis has not been reported yet. Here we report a case of renal artery thrombosis which developed in a patient with acute pyelonephritis complicated with sepsis-induced disseminated intravascular coagulation (DIC). A 65-year-old woman with diabetes was diagnosed with acute pyelonephritis complicated with sepsis. Escherichia coli was isolated from both blood and urine cultures. When treated with antibiotics, her condition gradually improved. She suddenly complained of severe right flank pain without fever in the recovery phase. A computed tomography scan revealed right renal artery thrombosis with concomitant renal infarction. Prophylactic anticoagulation therapy was not suggested because of sustained thrombocytopenia and increased risk of bleeding. Flank pain resolved with conservative treatment and perfusion of infarcted kidney improved at the time of discharge. To our knowledge, this is the first case of renal artery thrombosis related to acute pyelonephritis with sepsis-induced DIC.

A Case of Hemolytic Uremic Syndrome in a Lung Cancer Patient Treated with Gemcitabine / 결핵및호흡기질환

Hemolytic uremic syndrome (HUS) is a rare disorder characterized by the triad of microangiopathic hemolytic anemia, thrombocytopenia, and acute renal failure. HUS arises from a wide spectrum of conditions, and chemotherapeutic agents have been reported to be associated with HUS, including Mitomycin, Cisplatin, Bleomycin, and Gemcitabine. A 76-year-old man treated with Gemcitabine due to non-small cell lung cancer developed clinical and laboratory findings compatible with HUS. Gemcitabine was ceased and hemodialysis and plasma exchange were utilized and he recovered. A high level of suspicion for HUS is necessary when cancer patients are treated with Gemcitabine, and prompt recognition and treatment are also essential.

Clinical Characteristics and Risk Factors of Acute Kidney Injury in Patients with Acute Alcohol Intoxication / 대한신장학회지

PURPOSE: Acute alcohol intoxication (AAI) causes various complications such as electrolyte imbalance, alcoholic ketoacidosis (AKA), rhabdomyolysis, and acute kidney injury (AKI). Although there have been some reports about AKA and rhabdomyolysis, AKI due to acute alcohol intoxication is rarely reported. METHODS: We retrospectively evaluated the medical records of 371 patients with AAI between January 2004 and May 2010 in Uijeongbu St. Mary's Hospital. We compared the clinical findings, morbidity and mortality rate between AKI and normal kidney function (NKF) groups. RESULTS: Of the total 371 patients with AAI, AKI occurred in 107 patients (28.8%). The peak serum creatinine level in AKI patients was 2.9+/-1.9 mg/dL. Thirteen of the 107 patients (12.1%) received renal replacement therapy. AKI group had higher incidence of decreased mentality (29.0% vs 16.3%, p=0.006), dyspnea (11.2% vs 4.9%, p=0.029) and hypotension (66.0% vs 41.7%, p<0.001), and lower incidence of gastrointestinal bleeding (22.4% vs 34.8%, p=0.019), compared to NKF group. The AKI group also had higher incidence of ketoacidosis (78.5% vs 28.8%, p<0.001), rhabdomyolysis (19.6% vs 4.2%, p<0.001), and pneumonia (22.4% vs 8.0%, p<0.001), compared to NKF group. The length of ICU stay was longer (7.4+/-10.8 vs 4.1+/-6.1 days, p=0.003) and the mortality rate was higher (17.8% vs 2.3%, p<0.001) in AKI group. CONCLUSION: This study demonstrated that incidence of AKI in patients with AAI was 28.8% and AKI was associated with high morbidity and mortality. And multivariate analysis demonstrated that independent risk factors of AKI were ketoacidosis and increased serum osmolality.

A Case of Pituitary Apoplexy Misdiagnosed as Aseptic Meningitis / 대한내과학회지

Pituitary apoplexy is a clinical syndrome caused by an acute ischemic or hemorrhagic vascular accident. Although pituitary apoplexy is an emergency, it is often overlooked because it is rare and presents with various signs and symptoms, including those of neurologic and endocrine disorders. We describe a case of pituitary apoplexy misdiagnosed as aseptic meningitis accompanied by acute-onset headache and nausea, followed by fever. Subsequently, it was revealed as pituitary apoplexy by brain magnetic resonance imaging (MRI) performed when the clinical course worsened and ophthalmoplegia developed. We suggest that pituitary apoplexy be included in the differential diagnosis of patients presenting with headache or signs of meningeal irritation; when there is no clinical improvement, prompt steroid treatment should be started, while considering neurological decompression to prevent neurological sequelae.

A Case of Hemicranial Pneumocephalus Secondary to Removal of a Central Venous Catheter / 대한내과학회지

The presence of pneumocephalus associated with insertion, maintenance, and removal of intravenous catheters is a rare radiographic finding, but may be clinically relevant. Various pathways have been proposed to explain the development of pneumocephalus, but none are well understood. We present a patient with hemicranial pneumocephalus secondary to removal of a central venous catheter as determined by computed tomography, and we propose a possible mechanism of the pneumocephalus.

Myeloid Sarcoma in Patients with RUNX1/RUNX1T1 Positive AML and a c-kit Mutation / 대한내과학회지

t (8;21)(q22;q22) is the most frequently detected cytogenetic abnormality in patients with acute myeloid leukemia (AML) and accounts for 8-21% of de novo AML. The translocation involves two genes, RUNX1 (formerly AML1) on 21q22 and RUNX1T1 (ETO) on 8q22. RUNX1/RUNX1T1 translocation confers a favorable prognosis, but a subset of patients has a precipitous course with a high incidence of relapse. This patient subset is associated with the presence of a c-kit mutation. c-kit is a proto-oncogene, which encodes a type III transmembrane tyrosine kinase, which elicits a variety of cellular responses essential for the development of bone marrow stem cells. The expression of the c-kit mutation in AML is < 2%, whereas AML with RUNX1/RUNX1T1 shows higher rates of c-kit mutation and is associated with extramedullary leukemia and poor clinical outcome. We report cases of myeloid sarcoma in patients with RUNX1/RUNX1T1-positive AML and a c-kit mutation.

A Case of Minimal Change Nephrotic Syndrome Presented as Portal Vein Thrombosis and Acute Renal Failure / 대한신장학회지

Patients with the nephrotic syndrome are at risk of developing thromboembolic complications. Much evidence suggests that a hypercoagulable state exists in the setting of the nephrotic syndrome, but the exact mechanisms are poorly understood. The nephrotic syndrome associated with portal vein thrombosis is relatively uncommon. We experienced a case of minimal change nephrotic syndrome presented as portal vein thrombosis and acute renal failure. On renal biopsy, electron microscopic examination reveals diffuse foot process effacement. Treatment with corticosteroid and anticoagulation resulted in complete remission of proteinuria.

A Case of Central Vein Stenosis Complicated by Calcified Lesions of Pulmonary Tuberculosis / 대한신장학회지

Central venous stenosis or occlusion is commonly associated with placement of central venous catheters or devices. Although rare, central venous stenosis or occlusion may also develop without a history of previous central venous catheter placement. Here we report a case of central venous stenosis without a previous central catheter placement. A 76-year-old woman with hypertensive nephropathy was admitted due to deterioration of renal function. Tunneled cuffed catheter for hemodialysis was inserted in the right external jugular vein, and we intended to insert central venous catheter because of poorly functioning peripheral vein. But, left internal jugular vein was not cannulated. The patients had a history of pulmonary tuberculosis and chest x-ray revealed extensive calcified lesions mainly in left upper lung. Venography and CT angiogram showed complete occlusion at the confluent point of the left subclavian vein and left internal jugular vein, and left brachiocephalic vein by calcified lesion. The anterior cervical vein and jugular venous arch forming an anastomosis between the neck vein were marked dilated. The patient did not show any clinical symptoms and signs associated with central venous stenosis, and the central venous catheter functioned well, correction of central vein stenosis was not necessary. After the supportive care including temporary hemodialysis, the patient improved from renal dysfunction.

Acute Coronary Syndrome Mimicking Atypical Stress-Induced Cardiomyopathy in a Patient with Panhypopituitarism

Stress-induced cardiomyopathy is frequently confused with acute coronary syndromes. We encountered a 64-year old female patient with panhypopituitarism initially suspected as atypical stress-induced cardiomyopathy due to her history and initial echocardiographic findings. She was finally diagnosed as non ST-segment elevation myocardial infarction based on the findings of coronary angiogram, intravascular ultrasound and subsequent echocardiogram.