Multiple Endocrine Neoplasia Type 1 Presenting with an Invasive Giant Prolactinoma / 대한내과학회지

Pituitary tumors occur in 15-50% of patients with multiple endocrine neoplasia of type 1 (MEN1). To the best of our knowledge, no MEN1 case in which the initial lesion was an invasive giant prolactinoma has been reported from Korea. We describe a patient in whom a skull-base tumor involved the sellar and parasellar spaces. A 49 year-old female presented with headache and diplopia. The tumor was ultimately identified as a giant prolactinoma; the serum prolactin concentration increased from 155.6 ng/mL to 3,234.3 ng/mL after cranial irradiation. She was evaluated in terms of incidental hypercalcemia and was found to have parathyroid hyperplasia. Genetic analysis revealed a missense mutation in the MEN1 gene (c.643G>A, p.Val215Met). Two years of treatment with a dopamine agonist reduced, but did not normalize, the serum prolactin concentration. We highlight the aggressive behavior of the giant skull-base tumor, and the diagnostic delay caused by a high-dose hook effect of the MEN1-related prolactinoma.

Importance of Regular Follow-Up Examination during Active Surveillance: a Case of Anaplastic Transformation of Papillary Thyroid Microcarcinoma

Because papillary thyroid carcinoma (PTC) is indolent and has an excellent prognosis, active surveillance, without immediate surgery, can be considered for small PTC. However, rarely, PTC can transform to anaplastic thyroid carcinoma (ATC), over a period of 5-20 years. We report 73-year-old man with rapid anaplastic transformation of a PTC. He was diagnosed with colorectal cancer, and a 1-cm-sized thyroid nodule was found incidentally and confirmed as PTC on fine-needle aspiration. He underwent transanal excision and chemotherapy for colorectal cancer. However, he was not concerned about the PTC, and no follow-up examination was performed. After 37 months, he suddenly noticed an enlarging neck mass, which was diagnosed as an ATC. Despite total thyroidectomy, locally advanced recurrence with lung metastasis developed, and he eventually died. Although PTC is indolent and progresses slowly in elderly people, it can transform to ATC. Therefore, during active surveillance in the elderly, follow-up examinations should be performed regularly.

Importance of Regular Follow-Up Examination during Active Surveillance: a Case of Anaplastic Transformation of Papillary Thyroid Microcarcinoma

Because papillary thyroid carcinoma (PTC) is indolent and has an excellent prognosis, active surveillance, without immediate surgery, can be considered for small PTC. However, rarely, PTC can transform to anaplastic thyroid carcinoma (ATC), over a period of 5-20 years. We report 73-year-old man with rapid anaplastic transformation of a PTC. He was diagnosed with colorectal cancer, and a 1-cm-sized thyroid nodule was found incidentally and confirmed as PTC on fine-needle aspiration. He underwent transanal excision and chemotherapy for colorectal cancer. However, he was not concerned about the PTC, and no follow-up examination was performed. After 37 months, he suddenly noticed an enlarging neck mass, which was diagnosed as an ATC. Despite total thyroidectomy, locally advanced recurrence with lung metastasis developed, and he eventually died. Although PTC is indolent and progresses slowly in elderly people, it can transform to ATC. Therefore, during active surveillance in the elderly, follow-up examinations should be performed regularly.

Anti-tuberculosis Treatment-Induced Insulin Autoimmune Syndrome / 이화의대지

Insulin autoimmune syndrome, a rare cause of endogenous hyperinsulinemic hypoglycemia, is characterized by insulin autoantibody, hyperinsulinemia and fasting hypoglycemia. It is well known that drugs containing a sulfhydryl group such as methimazole or α-mercaptopropionyl glycine can induce insulin autoimmune syndrome. However, insulin autoimmune syndrome caused by anti-tuberculosis treatment is very rare. We report a case of insulin autoimmune syndrome after anti-tuberculosis treatment with a review of the relevant literature.

The causes of difficult tracheal intubation and preoperative assessments in different age groups / 대한마취과학회지

BACKGROUND: We studied the differences in airway assessment factors among old, middle, and young age groups, and evaluated the frequency and causes of difficult intubation among these groups. METHODS: Patients were divided into young ( or = 60 yr, n = 89) group. Airway assessment factors such as head and neck movement, thyromental distance, interincisor gap, dentition, Mallampati score, and Arne score were assessed. After muscle relaxation, cervical joint rigidity and Cormack-Lehane (C-L) grade were assessed. The differences in airway assessment factors between difficult (C-L grade 3, 4) and easy (C-L grade 1, 2) intubation were then examined. Logistic regression analysis was also carried out to identify the extent to which airway assessment factors reflected difficult intubation. RESULTS: As aging, head and neck movement, thyromental distance, and interincisor gap decreased, the grade of dentition, Mallampati score, cervical joint rigidity and the ratio of Arne score > 11 increased. In the old and middle group, the incidence of difficult intubation was increased compared with the young group. Dentition in the young group, Mallampati score and interinsisor gap in the middle group and Mallampati score, cervical joint rigidity in the old group respectively predicted difficult intubation. CONCLUSIONS: Compared to young individuals, middle-aged or elderly adults are likely to experience more difficulty in endotracheal intubation and its predictive factors could vary by age group.

Suspected anaphylactic shock during the induction of general anesthesia in a child: A case report

Anaphylaxis is rarer in children than adults. The immediate onset and rapid clinical course makes it difficult to diagnose, and it can be life-threatening. Neuromuscular agents during anesthesia can cause severe anaphylactic shock in rare cases. We report on a pediatric patient with anaphylaxis after rocuronium injection during the induction of general anesthesia. A 5-year-old girl was scheduled for a tonsillectomy and a myringotomy with ventilating tube for tonsil hypertrophy. Her preoperative medical history and laboratory findings were not remarkable. In the operating room, we injected ketamine, glycopyrrolate and rocuronium for general anesthesia. Immediately after rocuronium injection, she developed hypotension, tachycardia, cyanosis, edema, and wheal, and was treated for suspected anaphylactic shock. After proper treatment, her conditions improved without any complications, and she was discharged uneventfully 1 day later.

Conversion phenomenon during the induction period of general anesthesia: A case report / 대한마취과학회지

Conversion disorder is characterized as psychological symptoms such as somatization and emotional distress, but there is no abnormal electrical signal in the brain. We report a patient who appeared conversion disorder during the induction period of general anesthesia. A 45-year-old woman was planned for arthroscopic knee meniscectomy. In the operating room, she appeared stable, but she said extremely nervous in this situation. Before propofol injection for induction of anesthesia, we injected 1% lidocaine 50 mg iv for pain relief. Immediately after injection, she showed general seizure-like activity and then tonic-rigid muscle tone, dyspnea with periodic breathing without cyanosis, and clouding of consciousness. The operation was delayed, and she was examined by neurosurgeon and psychiatrist. She was diagnosed as suffering with conversion disorder and she was without brain abnormalities on the magnetic resonance imaging. Her condition improved after anti-depressant medication and supportive psychotherapy. She underwent uneventful knee surgery 40 days later.

The Effect of an Intraperitoneal Injection of Ketamine and Ketorolac on Mechanical Allodynia in Rats with Spinal Nerve Ligation / 대한마취과학회지

BACKGROUND: It is difficult to manage the symptoms of neuropathic pain, especially alloynia. The mechanism of the induction and maintenance of mechanical allodynia has been extensively researched for several decades. N-methyl-D-aspartate (NMDA) receptor antagonists are known to reduce mechanical allodynia. Recently, the role of prostaglandins in spinal nociceptive processing has been the focus of attention. Therefore, the present study was designed to investigate the effect of a combination of ketamine, a non-competitive NMDA antagonist, and of ketorolac, non-selective cyclooxygenase (COX) inhibitor on mechanical allodynia. METHODS: Male SD rats were prepared by tightly ligating the left L5 and L6 spinal nerves. All rats developed mechanical allodynia 7 days after surgery. N group (control, n = 6) received 5 ml of 0.9% normal saline intraperitoneally. K group (n = 6) received ketamine 1 mg/kg. T group received ketorolac 30 mg/kg, and KT group received ketamine 1 mg/kg and ketorolac 30 mg/kg simultaneously. Paw withdrawal thresholds to von Frey hairs were measured before and at 15 min, 30 min, 60 min and 120 min after drug administration. RESULTS: Normal saline and ketamine 1 mg/kg did not increase the paw withdrawal threshold from baseline. Ketorolac 30 mg/kg increased the paw withdrawal threshold only at 120 min after intraperitoneal injection. However, the co-administration of ketamine 1 mg/kg and ketorolac 30 mg/kg increased the paw withdrawal threshold significantly from baseline for 120 min. CONCLUSIONS: Intraperitoneal injection of ketamine and ketorolac attenuated the mechanical allodynia developed by spinal nerve ligation. Therefore, we suggest that combination of ketamine and ketorolac might be useful for the management of neuropathic pain.

Clinical Experience of General Anesthesia in a Child with Status Epilepticus Induced by Febrile Convulsion: A case report / 대한마취과학회지

When continuous seizures are refractory to conventional intravenous anticonvulsant drugs, general anesthesia has been recommended to control status epilepticus. We present the case of a 6-year-old male patient who was admitted for generalized tonic-clonic status epilepticus secondary to febrile convulsion due to an upper respiratory infection. The tonic-clonic status epilepticus was refractory to all anticonvulsant measures and drugs including, phenytoin, phenobarbital, diazepam and lorazepam. After about 32 hours of unsatisfactory seizure activity control, we started general anesthesia for the management of his status epilepticus. After discontinuing general anesthesia, the patient developed a small number of episodes of epilepsia partialis, but seizure activity was well controlled by conventional anticonvulsants. The patient was extubated after three days and was discharged from hospital as cured 12 days after general anesthesia management.

Clinical Experience of General Anesthesia in a Child with Status Epilepticus Induced by Febrile Convulsion: A case report / 대한마취과학회지

When continuous seizures are refractory to conventional intravenous anticonvulsant drugs, general anesthesia has been recommended to control status epilepticus. We present the case of a 6-year-old male patient who was admitted for generalized tonic-clonic status epilepticus secondary to febrile convulsion due to an upper respiratory infection. The tonic-clonic status epilepticus was refractory to all anticonvulsant measures and drugs including, phenytoin, phenobarbital, diazepam and lorazepam. After about 32 hours of unsatisfactory seizure activity control, we started general anesthesia for the management of his status epilepticus. After discontinuing general anesthesia, the patient developed a small number of episodes of epilepsia partialis, but seizure activity was well controlled by conventional anticonvulsants. The patient was extubated after three days and was discharged from hospital as cured 12 days after general anesthesia management.

Accidental Intravenous Administration of Magnesium Sulfate during Cesarean Section: A case report / 대한마취과학회지

We report a case of the accidental intravenous administration of a large dose of magnesium sulfate during cesarean section. A 41-year-old woman, at 33 weeks gestation, with pregnancy-aggravated hypertension, headache and generalized edema presented in acute labor and showed fetal bradycardia on a nonstress test. Laboratory tests demonstrated an increased level of magnesium (5.4 mg/dl). A cesarean section was performed under general anesthesia with O2-N2O-enflurane and vecuronium. After delivery 2,000 mg of magnesium sulfate was mixed with the lactated Ringer's solution 1,000 ml and 550 ml administered to the patient. After noticing the accidental infusion of the magnesium sulfate, we replaced the lactated Ringer's solution with normal saline 1,000 ml and performed arterial blood gas analysis, checked serum electrolyte, including Mg2+ and Ca2+, and had monitored depth of muscle relaxation and vital signs. The level of magnesium had increased to 8.9 mg/dl after the accidental magnesium infusion. For about one and half hours after emergence from general anesthesia, she complained of dyspnea and paraparesis of extremities. To treat the hypermagnesemia, 3% calcium gluconate 1,000 mg and furocemide were given intravenously to antagonize magnesium and to increase the urine output. The depth of neuromuscular block was frequently monitored using a nerve stimulator. After conservative treatment, she recovered from the effect of the hypermagnesemia and was discharged on the fifth postoperative day. Anesthesiologists must to keep in mind the preoperative patients' pathophysiologic conditions, check co-administered drugs and the contents of intravenously connected solutions.