Accidental left atrial appendage thrombus detected by intraoperative transesophageal echocardiography during coronary artery bypass graft: A case report

A 77-year-old woman was scheduled for a coronary artery bypass graft. Her preoperative transthoracic echocardiographic (TTE) examination revealed an enlarged left atrium with reduced systolic dysfunction (ejection fraction: 38%), moderate global hypokinesia of the left ventricle, and moderate mitral and tricuspid regurgitation. No thrombus was visualized on the preoperative TTE. However, the intraoperative transesophageal echocardiography performed before the cardiopulmonary bypass revealed a thrombus of approximately 1.3 × 1.8 cm in the left atrial appendage (LAA). The LAA thrombus was removed, an internal suture was placed on the LAA before the coronary artery bypass grafting, and the main operation was performed successfully. The patient was transferred to the intensive care unit to receive postoperative care. She was extubated 4 h after the surgery and was transferred to the general ward on postoperative day 3 without any neurological sequelae.

Clinical Characteristics of Vivax Malaria and Analysis of Recurred Patients / 감염과화학요법

BACKGROUND: Plasmodium vivax malaria is an acute debilitating illness characterized by recurrent paroxysmal fever and relapses from hypnozoites in the liver. Although a few studies reported clinical characteristics of vivax malaria in civilians after reemergence in the Republic of Korea, only a small group of patients was analyzed. MATERIALS AND METHODS: We retrospectively reviewed the medical records of patients who had been diagnosed with vivax malaria by peripheral blood smear in a university-affiliated hospital located in a malaria-endemic area between January 2005 and December 2009. RESULTS: During the study period, a total of 352 malarial cases from 341 patients were diagnosed. Vivax malaria was most commonly developed in July and August, 24.7% (87/352), and 21.9% (77/352), respectively. The mean (SD) age was 42.5 (14.7) years and the number of male patients was 243 (71.3%). Six patients had a previous history of vivax malaria from 6 months to 10 years before. A total of 337 patients (98.8%) had fever and the mean (SD) body temperature was 38.3 (1.4)degrees C. Common associated symptoms were chills (213/341, 62.5%), headache (115/341, 33.7%), and myalgia (85/341, 24.9%). Laboratory findings included thrombocytopenia (340/341, 99.7%), anemia (97/341, 28.5%), leukopenia (148/341, 43.4%), increase of aspartate transaminase (177/341, 51.9%), and increase of alanine transaminase (187/341, 54.8%). Hypotension (14/341, 4.1%), altered mentality (3/341, 0.9%), azotemia (3/341, 0.9%), spleen infarction (2/341, 0.6%), and spleen rupture (1/341, 0.3%) developed as complications. Chloroquine was administered to all patients and primaquine was administered with mean (SD) 3.39 (0.82) mg/kg to 320 patients. There were 11 recurrent infections during the study period. The median (range) time to recurrent infection was 100 (32-285) days. Platelet counts were higher (86,550 vs. 56,910/mm3) and time to treatment of malaria was shorter (5 vs. 7 days) in relapsed cases compared with first occurrence cases (P=0.046). CONCLUSIONS: The overall recurrence rate of vivax malaria was 3.2% (11/341) in this study. In recurred cases, malaria was diagnosed earlier and thrombocytopenia was less severe. To evaluate the risk factors associated with recurrence and adequate dose of primaquine in Korean patients, further large-scale prospective studies will be needed.

Risk Factors of Cryptogenic Hepatocellular Carcinoma in Patients with Low Body Mass Index or without Metabolic Syndrome

BACKGROUND/AIMS: Many patients are diagnosed with cryptogenic hepatocellular carcinoma (HCC) without metabolic syndrome (MS). We investigated the risk factors for cryptogenic HCC in patients with a low body mass index (BMI) or without MS. METHODS: Thirty-six patients were diagnosed with cryptogenic HCC over a 10-year period at a tertiary research hospital. Data including BMI score and risk factors for MS were analyzed retrospectively. Patients with fewer than two risk factors for MS (n = 16) were compared with those with two or more risk factors (n = 20). Patients with high BMI (> or = 23 kg/m2, n = 20) were also compared with those with lower BMI (n = 16). RESULTS: Patients with fewer than two risk factors for MS were significantly more likely to smoke and be hepatitis B surface antibodies (anti-HBs)-positive vs. patients with two or more risk factors. However, only smoking was statistically significant on multivariate analysis. Peaks of BMI were observed in two regions. Lower BMI was significantly associated with the presence of anti-HBs compared with high BMI, although this association was not statistically significant on multivariate analysis. CONCLUSIONS: Smoking is a potential risk factor for cryptogenic HCC in patients without MS. Remote hepatitis B virus infection may be a risk factor for cryptogenic HCC in patients without MS or with a low BMI.

Stenting of the Left Main Coronary Artery in a Patient With Takayasu's Arteritis

Management of Takayasu's arteritis of the left main coronary artery (LMCA) is difficult because of the possibility of restenosis. Clinically significant stenotic lesions must be considered anatomical correlation. Many studies have reported that the management of stenotic lesions of the LMCA with endoluminal stenting and balloon angioplasty and de-novo stenting is safe and effective for patients with Takayasu's arteritis. We report the case of a patient with Takayasu's arteritis of the LMCA. The patient had undergone two consecutive percutaneous coronary interventions because of recurrent restenosis of in-stent lesions, and eventually underwent coronary artery bypass graft (CABG) surgery for myocardial infarction in the same lesion. We suggested treatment with CABG because the pathophysiology of Takayasu's arteritis is different from that of atherosclerotic stenosis.

Relapsing Kocuria varians Peritonitis in a Continuous Ambulatory Peritoneal Dialysis Patient / 대한신장학회지

Kocuria species are the normal flora of skin, mucosa and oropharynx, and can be the causative organisms of complications associated with intravenous catheterization, ambulatory peritoneal dialysis, and ventricular shunt. We report a case of relapsing peritonitis by Kocuria varians in a patient undergoing continuous ambulatory peritoneal dialysis (CAPD). A 62 year old woman was admitted to the hospital with a complaint of abdominal pain and a turbid peritoneal dialysate. The patient was treated with a combination of intraperitoneal antibiotics. A culture of the peritoneal dialysate revealed K. varians, and the patient was discharged after she showed improvement with the treatment. Although the organism was sensitive to the administered antibiotics, the patient experienced 2 episodes of peritonitis. This continuing recurrence could be attributed to an insufficient treatment period or biofilm formation. Therefore, the patient underwent further treatment with intraperitoneal antibiotics and showed no recurrence for 1 year thereafter. This is the first report of relapsing peritonitis by K. varians. Although peritonitis caused by rare pathogens has been described recently, K. varians is known to have a low pathogenecity and occurs rarely. The findings in this case emphasize the importance of careful consideration on the rare pathogen and administration of the appropriate antibiotics for a sufficient duration.

A Case of Tumoral Calcinosis in a Hemodialysis Patient with Secondary Hyperparathyroidism / 대한신장학회지

Tumoral calcinosis is a periarticular calcific lesion and rare complication in patients with maintenance hemodialysis. The pathogenesis of tumoral calcinosis is poorly understood but may be due to elevated serum phosphorus, a high calcium phosphorus (Ca x P) product or secondary hyperparathyroidism in hemodialysis patients. A 30-year-old man presented with pain and palpable mass of left shoulder. He had been on maintenance hemodialysis with high flux dialyzer for 10 years. Laboratory finding showed hyperphosphatemia and elevated intact PTH concentration. A shoulder X-ray and CT scan demonstrated a massive calcification. Following partial resection, pain was relieved. Here we report a case of tumoral calcinosis of shoulder in a hemodialysis patient with untreated hyperphosphatemia and secondary hyperparathyroidism.

A Case of Septic Shock Caused by Escherichia coli after Intravenous Injection of Contaminated Propofol / 감염과화학요법

Propofol (2,6-diisopropylphenol) is a rapid and short-acting anesthetic agent that is used for general anesthesia and endoscopic sedation. It is available as an aqueous lipid emulsion and this preparation could serve as a bacterial culture medium. We report a case of a 46-year-old female who developed septic shock caused by Escherichia coli after being sedated by propofol to undergo gastrointestinal endoscopy. The contaminated propofol was identified as the cause of septic shock by pulsed-gel electrophoresis.

Cytomegalovirus Colitis with Ulcerative Colitis in the Steroid Naive Immunocompetent Patient / 대한소화기내시경학회지

Ulcerative colitis is an idiopathic chronic inflammatory bowel disease that exclusively involves the colon. It is characterized by diffuse mucosal inflammation and a recurrent course of remission and relapse. Factors such as smoking, diet, genetic factors and miocrobial infection have all been suggested as causes of ulcerative colitis. One of the important issues in the treatment of ulcerative colitis is opportunistic infection associated with the usage of corticosteroid and immunosuppresant. In most cases, opportunistic cytomegalovirus infection after treatment with corticosteroid or immunosuppressant worsens the course of ulcerative colitis. However, cytomegalovirus infection is uncommon in immunocompetent patients and it is rare in immunocompetent patients with corticosteroid naive ulcerative colitis. We report here on a case in which an immunocompetent patient was newly diagnosed with ulcerative colitis and cytomegalovirus coinfection simultaneously.

Effect of Volume on Hypobaric Spinal Anesthesia for Perianal Surgery with Prone Jacknife Position / 대한마취과학회지

The effect of anesthetic volume on the spread of hypobaric tetracaine were sutdied after intrathecal injection in thirty patients with prone jackknife and 15 degree Trendelenburg position for perinal surgery. The patients were assigned randomly into the one of three groups divided by the 3, 4, or 5 ml of volume of anesthetic solution. The results show that the volume of tetracaine in distilled water with hypobaric spinal anesthesia in prone jackknife and l5 degree Trendelenburg position had a important effect on the anesthetic dermatomal levels in spite of slightly rapid onset with large. volume. Therefore, we concluded that for the perianal surgery in prone jackknife position, as the volume of the anes- thetic solution with hypobaric spinal anesthesia, 3 or 4 ml of the volume are sufficient to get the adequate anesthetic levels.

A Study of Household Contacts of Cases with Pulmonary Tuberculosis

When a Korean child is living in close contact with a person with active pulmonary tuberculosis, the risk of his acquiring the disease is great. In seeking an effective means of reducing this risk to the chi1d, isoniazid was given as secondary chemoprophylaxis to 233 tuberculin-positive children under 5 years of age who were clinically free of disease but were living in close contact with a household member with active tuberculosis. The condition of these children after 9 to 12 months of chemoprophylaxis was compared with a similar control group of 216 children living under exact1y comparable circumstances. An analysis of tile results of this study indicates that secondary chemoprophylaxis with isoniazid is effective and worthwhile for children under 4 years of age who are under constant exposure to tuberculosis. That there was such a protection is indicated by the fact that (1) isoniazid markedly reduced the size of the tuberculin reaction and that (2) only 2 children receiving isoniazid developed active tuberculosis (0.8%) as against the 8 controls who did (3.70%). The faithful cooperation of parents in administering prophylactic isoniazid to small children is often difficult to obtain. This difficulty is suggested by the fact that in the case of the 2 children in the isoniazid test group who developed active tuberculosis, the actual drug intake had been irregularly given and amounted to less than half the prescribed dose.