Massive Duodenal Bleeding after the Migration of Endovascular Coils into the Small Bowel

Among gastrointestinal emergencies, acute upper gastrointestinal bleeding remains a challenging clinical problem owing to significant patient morbidity and costs involved in management. Endoscopic hemostatic therapy is the mainstay of treatment and decreases the incidence of re-bleeding, the need for surgery, morbidity, and mortality. However, in 8%–15% of patients with upper gastrointestinal bleeding, endoscopic hemostatic therapy does not successfully control bleeding. Trans-arterial coil embolization is an effective alternative treatment for endoscopic hemostatic failure; however, this procedure can induce adverse outcomes, such as non-target vessel occlusion, vessel dissection and perforation, and coil migration. Coil migration is rare but causes severe complications, such as re-bleeding and bowel ischemia. However, in most cases, coil migration is local and involves spontaneous healing without serious complications. Here, we report the case of a patient who underwent trans-arterial coil embolization of the gastroduodenal artery with the purpose of controlling massive duodenal bleeding, resulting in a fatal outcome caused by coil migration.

Bacteremia due to Rahnella aquatilis in a Patient with a Chemoport / 감염과화학요법

Rahnella aquatilis, a saprophytic organism, is a member of the Enterobacteriaceae family. The natural habitat of this organism is fresh water, and it is rarely found in clinical specimens. Clinical conditions ascribed to this organism include bacteremia, respiratory infection, urinary tract infection, wound infection in an immunocompromised host, and infective endocarditis in patients with congenital heart diseases. Here, we report a case of bacteremia due to R. aquatilis in a woman with breast cancer who had received chemotherapy through a chemoport. To our knowledge, this is the second case of bacteremia caused by this organism in a patient with cancer in Korea.

Severe Hyponatremia with Mental Change after Ingestion of Picosulfate Sodium/Magnesium Citrate for Bowel Preparation / 대한내과학회지

Picosulfate sodium/Magnesium citrate (PS/MC) is a common bowel cleansing agent for colonoscopy. It is equally effective and better tolerated by patients with regard to taste and volume than polyethylene glycol. However, because of its osmotically active characteristics, PS/MC can cause plasma volume depletion and electrolyte disturbances, such as hyponatremia. Here, we report a case of severe hyponatremia combined with loss of consciousness in a 59-year-old woman following ingestion of PS/MC as bowel preparation for a screening colonoscopy. Upon arrival, serum sodium level was 109 mEq/L and urine osmolality and sodium levels were 393 mOms/Kg and 99 mmol/L, respectively. She was euvolemic and showed normal kidney, thyroid, and adrenal function. Based on these findings, inappropriate anti-diuretic hormone syndrome (SIADH) was diagnosed. She was treated with 3% hypertonic saline and completely recovered without any neurologic sequelae. This case shows that SIADH can be caused by PS/MC (not accompanied by dehydration), even in patients without any underlying renal, heart, or liver diseases.

Increased Detection of Colorectal Polyps in Screening Colonoscopy Using High Definition i-SCAN Compared with Standard White Light

BACKGROUND/AIMS: The aim of this study was to evaluate the efficacy of high definition (HD) i-SCAN for colorectal polyp detection in screening colonoscopy. METHODS: We retrospectively analyzed the records of 501 patients who had undergone screening colonoscopy performed by three endoscopists with either HD i-SCAN (n=149) or standard white light (n=352) from January 2, 2014 through June 30, 2014. Patient information and inter-endoscopist variation as well as polyp number, endoscopic findings, and pathologic characteristics were reviewed. RESULTS: The detection rates of colorectal and neoplastic polyps were significantly higher using HD i-SCAN than standard white light colonoscopy (52% vs. 38.1%, p=0.004 for colorectal polyps; and 37.2% vs. 27.9%, p=0.041 for neoplastic polyps). Analysis of endoscopic findings revealed no difference in detected polyp size between HD i-SCAN and standard white light colonoscopy (4.59+/-2.35 mm vs. 4.82+/-2.81 mm, p=0.739), but non-protruding polyps were more commonly detected by i-SCAN than by standard white light colonoscopy (24.6% vs. 13.5%, p=0.007). CONCLUSIONS: Colonoscopy using HD i-SCAN had a significantly higher detection rate of colorectal polyps, including neoplastic polyps, because of improved sensitivity for detecting non-protruding lesions.

Development of Epidural and Paraspinal Abscesses after Insufficient Evaluation and Treatment of Acute Pyelonephritis Caused by Staphylococcus aureus / 가정의학회지

Diagnoses of pyelonephritis caused by Staphylococcus aureus should be accompanied by investigations of concomitant bladder obstruction and metastatic infections, especially to the spine or heart. Complicated pyelonephritis due to S. aureus requires more than 2 weeks of antibiotics, which is the typically recommended treatment duration for pyelonephritis. We describe a patient who was diagnosed with complicated epidural and paraspinal abscesses after insufficient evaluation and treatment of acute pyelonephritis due to S. aureus. A 62-year-old man with type 2 diabetes was admitted with fever, increased urinary frequency, and left flank pain. He was diagnosed with acute pyelonephritis caused by S. aureus. His fever and flank pain subsided after 3 days of intravenous antibiotics. Evaluation of bladder obstruction and metastatic infection were not performed, as he declined further evaluation. The patient was discharged with oral antibiotics and was requested to attend weekly appointments but was lost to follow-up. One month later, the patient presented at the outpatient clinic with similar symptoms. Computed tomography showed recurrent pyelonephritis and a distended bladder. His flank pain persisted despite administration of an opioid agent. Therefore, magnetic resonance imaging was performed, revealing epidural and paraspinal abscesses. Ultrasound-guided aspiration of the paraspinal muscle layer was performed, and blood and percutaneous aspirated fluid cultures revealed S. aureus growth. The pattern of antimicrobial sensitivity was identical to that at his first admission. Following more than 4 weeks of antibiotics, magnetic resonance imaging showed the abscesses had decreased in size. The patient was discharged without neurologic sequelae and was provided with oral antibiotics.

Hypereosinophilic Syndrome Presenting as Intussusception in Adults / 대한내과학회지

Hypereosinophilic syndrome (HES) is characterized by persistent eosinophilia associated with damage to multiple organs. Although the diagnostic criteria for HES include sustained hypereosinophilia for at least 6 months, early initiation of therapy may be recommended in patients exhibiting HES symptoms. Eosinophilic enteritis has been reported as a cause of intussusception in several cases. However, HES as a cause of intussusception has not yet been reported. In the present report, we describe a case of HES that manifested as jejunojejunal intussusception. Although long-standing hypereosinophilia was not confirmed, the patient required eosinophil-lowering therapy for an intestinal obstruction. The patient was treated with systemic corticosteroids, after which the symptoms and multiple organ involvement, including intussusception, improved dramatically, as noted on the radiological investigation. Moreover, surgery was not necessary.

Hypereosinophilic Syndrome Presenting as Intussusception in Adults / 대한내과학회지

Hypereosinophilic syndrome (HES) is characterized by persistent eosinophilia associated with damage to multiple organs. Although the diagnostic criteria for HES include sustained hypereosinophilia for at least 6 months, early initiation of therapy may be recommended in patients exhibiting HES symptoms. Eosinophilic enteritis has been reported as a cause of intussusception in several cases. However, HES as a cause of intussusception has not yet been reported. In the present report, we describe a case of HES that manifested as jejunojejunal intussusception. Although long-standing hypereosinophilia was not confirmed, the patient required eosinophil-lowering therapy for an intestinal obstruction. The patient was treated with systemic corticosteroids, after which the symptoms and multiple organ involvement, including intussusception, improved dramatically, as noted on the radiological investigation. Moreover, surgery was not necessary.

The Effect of Tetracaine.HCl on Rotational Mobility of n-(9-Anthroyloxy) Stearic Acid in Outer Monolayers of Neuronal and Model Membranes

To provide a basis for studying the pharmacological actions of tetracaine.HCl, we analyzed the membrane activities of this local anesthetic. The n-(9-anthroyloxy) stearic and palmitic acid (n-AS) probes (n = 2, 6, 9, 12 and 16) have been used previously to examine fluorescence polarization gradients. These probes can report the environment at a graded series of depths from the surface to the center of the membrane bilayer structure. In a dose-dependent manner, tetracaine.HCl decreased the anisotropies of 6-AS, 9-AS, 12-AS and 16-AP in the hydrocarbon interior of synaptosomal plasma membrane vesicles isolated from bovine cerebral cortex (SPMV), and liposomes derived from total lipids (SPMVTL) and phospholipids (SPMVPL) extracted from the SPMV. However, this compound increased the anisotropy of 2-AS at the membrane interface. The magnitude of the membrane rotational mobility reflects the carbon atom numbers of the phospholipids comprising SPMV, SPMVTL and SPMVPL and was in the order of the 16, 12, 9, 6, and 2 positions of the aliphatic chains. The sensitivity of the effects of tetracaine.HCl on the rotational mobility of the hydrocarbon interior or surface region was dependent on the carbon atom numbers in the descending order 16-AP, 12-AS, 9-AS, 6-AS and 2-AS and on whether neuronal or model membranes were involved in the descending order SPMV, SPMVPL and SPMVTL.

A Case of Lichen Amyloidosis / 대한피부과학회지

The primary cutaneous amyloidoses are divided into lichen, macular and nodular amyloidosis. Lichen amyloidosis is a chronic pruritic skin disorder characterized by deposition of amyloid material in previously normal skin, without evidence of visceral involvement, and presents as small, discrete, brownish gray papules. Prolonged friction, genetics, viral infection and the environment have been proposed as factors inducing lichen amyloidosis, but the precise pathogenesis of lichen amyloidosis is yet to be determined. We report herein a lichen amyloidosis occurring on the back of a 26-year-old woman who presented with 10-years history of chronic pruritic skin lesion.

Therapeutic Effect of Bleomycin Intralesional Injection on Keloids & Hypertrophic Scars / 대한피부과학회지

BACKGROUND: Keloids and hypertrophic scars are benign growths of dermal collagen that usually cause major physical, psychological, and cosmetic problems. Numerous treatment modalities have been used to treat keloids and hypertrophic scars, but the optimal treatment has not been established. OBJECTIVE: The purpose of this study is to investigate whether bleomycin intralesional injection has an therapeutic effect on both keloids and hypertrophic scars. METHODS: Thirteen patients with keloids or hypertrophic scars were administered with intralesional injection of bleomycin (1.5 IU/ml). Scar height was measured, and scar pliability and erythema were scored at baseline and then monthly during the treatment and follow-up period. Patient's self-assessments of subjective symptoms (pruritus and pain) were also scored. Pre- and post-treatment mean values for scar height, scar pliability, erythema, pruritus and pain were statistically compared. RESULTS: The clinical response was positive in all cases: highly significant flattening in one case, significant flattening in one case, moderate flattening in five cases and minimal flattening in six cases. The mean scores for pruritus and pain also improved. The observed side-effects were hyperpigmentation (two cases), hypopigmentation (one case) and skin infection (one case). No exacerbation was noted during follow-up period of 4 months. CONCLUSION: Bleomycin intralesional injecton may be one of the effective and safe method of treating keloids and hypertrophic scars.

A Case of Lichen Spinulosus / 대한피부과학회지

Lichen spinulosus is an uncommon idiopathic disorder characterized by scattered 2 cm to 6 cm patches of keratotic follicular papules. Individual papules are 1 to 3 mm in diameter and consist of a hairlike horny spine. Lesions are typically skin colored and asymptomatic or mildly pruritic. It occurs mainly in children and adolescents. Although several factors, such as atopy, infection, drug reaction, id reaction to fungal infection, and heredity, have been proposed as playing a role in lichen spinulosus, most cases are not associated with any systemic abnormalities. Lichen spinulosus is usually a symmetrical lesion that occurs on the trunk or extremities. Herein, we report a case of lichen spinulosus in a 7-year-old child in the submental area, an uncommon site.

A Case of Melanoacanthoma on the External Auditory Canal / 대한피부과학회지

Melanoacanthoma, a rare benign variant of seborrheic keratosis, was first introduced by Mishima and Pinkus in 1960. It is a slow-growing, painless, pigmented plaque with a verrucous surface and a diameter ranging from a few millimeters to 10 cm. It tends to develop during middle-age with an equal sex incidence, and the lesion usually presents on the head, trunk, and especially the lip. It also has a histopathologic finding of mixed neoplasm composed of melanocytes scattered throughout keratinocytic lobules, and is characterized by hyperkeratosis, parakeratosis, acanthosis, papillomatosis and pseudo-horn cysts in the epidermis. We report a case of melanoacanthoma occurring in a 52-year-old female, who presented with an easily bleeding mass on her right external auditory canal, an extremely uncommon site.

Lichen Striatus in a Girl: Successful Treatment with Pimecrolimus

Lichen striatus (LS) is a self-resolving condition, which may occasionally need treatment for significant pruritus, a persistent course or cosmetic problems. The options for treatment have usually been topical or intralesional corticosteroids, salicylic acid, coal tar, or more recently, topical tacrolimus and pimecrolimus. We report a case of LS successfully treated with pimecrolimus in a 15-year-old girl.

Erythema Ab Igne Caused by Weight Loss Heating Pad / 대한피부과학회지

Erythema ab igne (EAI) refers to the development of persistent areas of reticular erythema, often with pigmentation, at the sites of repeated exposures to heat, usually from open hearths. Although the incidence of EAI has declined due to the advent of central heating, various other causes have recently been reported, including hot water bottles, heating pads used to treat ailments, heated blankets, car heaters, and laptop computers. We present a case of 23-year-old Korean woman with an asymptomatic patch on her trunk, which had occurred a month before due to use of weight loss heating pad for weight reduction.

Treatment of Generalized Granuloma Annulare with Low-dose Hydroxychloroquine / 대한피부과학회지

Generalized granuloma annulare (GGA) is benign granulomatous dermatosis of unknown causes characterized by a widespread papular eruption on the trunk and limbs. This differs from the localized form as it is distinguished by later onset, a protracted response to therapy, and concomitant diabetes mellitus in 20% of patients. GGA is a chronic disease with a relapsing course and a poor long term response to treatment, GGA lasted for 5 or more years in 25% of patients. Thus, more safe and effective therapeutic modalities are needed. The effectiveness and safety of hydroxychloroquine (6.5 mg/kg/day) which has a long history of efficacy in systemic lupus erythematosus is identified. We report a case of 48-year-old man presented with GGA lesions successfully treated with a low dose hydroxychloroquine (3 mg/kg/day) without side effect and the clinical improvement observed after 2 weeks. Low doses of hydroxychloroquine might be beneficial in the treatment of GGA, compared with other drugs, with low potency of side effect.

A Case of Collision Tumor Involving Squamous Cell Carcinoma and Lentigo Maligna / 대한피부과학회지

The association of contiguous or "collision" tumors in the same biopsy specimen is uncommon, but often reported in foreign literature. Although some of these associations may arise from the involvement of related cell types, most are fortuitous. There are two or more common lesions juxtaposed by coincidence. The most commonly malignant association, basal cell carcinoma and melanoma, is very difficult to diagnose clinically. In this report, we describe a 80-year-old woman with squamous cell carcinoma and lentigo maligna arising at the same site on the left cheek. To the best of our knowledge, this is the first report of collision tumor comprising squamous cell carcinoma and lentigo maligna in Korean dermatological literature.

A Case of Melanoacanthoma

Melanoacanthoma is a variant of seborrheic keratosis which was first introduced by Mishima and Pinkus in 1960. This is a very rare and benign, epidermal tumor. Clinically, it is usually manifested in a pigmented, verrucous, round or oval plaque and nodular lesion. This is characterized histologically by nonpigmented keratinocytes and numerous large, richly dendritic melanocytes. We describe a 68-year-old man who suffered from a black-colored plaque on his right shin for 5 years. Melanoacanthoma was diagnosed by characteristic histopathologic findings.

A Case of Childhood Pernio Treated with Nifedipine / 대한피부과학회지

Pernio, or chilblains, are a localized inflammatory lesion of the skin resulting from an abnormal response to cold. The condition is characterized by cutaneous lesions located on the distal parts, such as the fingers, toes, nose and ears. Pernio develops among susceptible individuals who are exposed to non-freezing condition and most commonly occurs among young women and children. However, reports on childhood pernio are rarely found. Several conditions have been described as predisposing factors to pernio, including excessive cold exposure, low-grade vasculitis, the presence of cryoproteins, anorexia nervosa, systemic lupus erythematous and antiphospholipid antibodies. It is important, therefore, when evaluating a patient with chronic pernio who is resistant to conservative management, to exclude an underlying condition and also to determine whether additional testing is necessary. Herein, we present an uncommon case of a 5-year-old female patient with chronic pernio that may be associated with the presence of cold agglutinin. She received topical steroids prior to evaluation but no improvement was seen. Howere, treatment with calcium channel blocker, nifedipine, was of benefit to our patient.

A Case of Recurrent Clear Cell Hidradenoma / 대한피부과학회지

Clear cell hidradenoma is a relatively rare benign cutaneous tumor. Treatment of choice is surgical excision but there have been some reports in Korea of recurrence of clear cell hidradenoma after surgical excision. We report a case of a 33-year-old woman with recurrent clear cell hidradenoma which recurred twice on her left anterior thigh. The first lesion was noticed 8 years ago and excised surgically 6 years ago. Three years after the operation, the lesion recurred on the operation site and was excised again. But 3 months ago the lesion appeared again, so we performed wide, complete excision and made a diagnosis of clear cell hidradenoma.

A Case of Plexiform Neurilemmoma on the Upper Lip / 대한피부과학회지

Plexiform neurilemmoma is a rare variant of neurilemmoma characterized by a multinodular growth pattern which is originated from Schwann cells. Neurilemmoma most commonly occurs in the head, neck, and flexor surface of the extremities. Neurilemmoma also takes place in the oral cavity. Amongst the oral cavity, the tongue is frequently involved, but the lip rarely. To our knowledge, there has been one report in Korean dermatologic literature presenting a classical form of neurilemmoma on the upper lip. We report here in a case of plexiform neurilemmoma that showed typical histologic findings on the upper lip of a 37-year old woman. We present this rare case and review the literature briefly concerning neurilemmoma. Even though a plexiform neurilemmoma of the upper lip is very rare, it should be taken into consideration in the differential diagnosis of a lip mass.