A Case of Combined POEMS Syndrome and Multiple Myeloma with Positive M protein Only on Immunofixation

POEMS syndrome is a plasma cell proliferative disorder is characterized by the presence of peripheral neuropathy (P), organomegaly (O), monoclonal gammopathy (M), endocrinopathy or edema (E) and skin change (S). It can be rarely related to multiple myeloma. A 48-year-old man was admitted to our hospital due to paresthesia of both inguinal areas and weakness of both lower extremities. He had a history of Castleman's disease, and showed features of polyneuropathy, multiple osteoblastic lesions, hepatosplenomegaly, pretibial pitting edema, and papilledema. The serum and urine electrophoresis were negative, but urine immunofixagion could detect monoclonal protein. Plasmacytoma was confirmed through the biopsy for the osteoblastic lesions. We present a case of combined POEMS syndrome and multiple myeloma with positive M protein only on immunofixation in order to share our experience with physicians and specialists.

A Case of Brunner's Gland Hyperplasia of the Duodenal Second Portion with Annular Stricture Causing an Induced Obstruction / 대한소화기내시경학회지

Brunner's gland hyperplasia is a tumor arising from the Brunner's gland and the lesions account for 10.6% of benign duodenal tumors. These lesions are usually asymptomatic and detected incidentally by endoscopy or by a UGI barium study. In the case of severe and atypical forms, these lesions cause bleeding, intestinal obstruction or intussuception. However, Brunner's gland hyperplasia causing an annular duodenal stricture and subsequent intestinal obstruction has been rarely reported. We report here a very rare case of Brunner's gland hyperplasia presenting as an annular stricture and obstruction.

The Usefulness of Double Balloon Enteroscopy for Diagnosis and Treatment of Small Bowel Diseases

BACKGROUND/AIMS: Double balloon eneterscopy is a promising endoscopic method to examine the entire small bowel and to conduct therapeutic procedures. This study was performed to evaluate the clinical outcome and usefulness of double balloon enteroscopy. METHODS: We enrolled patients with suspected small bowel disease. Double balloon enteroscopy was performed in 61 patients and 89 procedures were undetaken between August 2004 and October 2007 at Hangang Sacred Heart Hospital. RESULTS: Indications for double balloon enteroscopy were obscure gastrointestinal bleeding, chronic abdominal pain or diarrhea and the presence of a suspicious small bowel tumor. Double balloon enteroscopy contributed to the diagnosis of small bowel diseases in 82.0% of patients. In 46 patients (75.4%), specific treatments were influenced by the results of double balloon enteroscopy. There were no significant complications. CONCLUSIONS: Double balloon enteroscopy is one of the most useful methods for the diagnosis and treatment of small bowel disease.

A Case of Pancreatic Arteriovenous Malformation Presenting Upper Gastrointestinal Bleeding / 대한소화기내시경학회지

A pancreatic arteriovenous malformation (AVM) is a very rare disease entity that is usually asymptomatic; however, it may present with a massive gastrointestinal hemorrhage. Recent advances in cross-sectional imaging and the widespread availability of angiography have contributed to the diagnosis of this condition. A patient was transferred to our clinic due to unknown origin gastrointestinal bleeding and upper abdominal pain. Double balloon enteroscopy and duodenoscopy revealed a bleeding pancreatico-cholangio-duodenal fistula. We were able to diagnose an arteriovnous malformation with a pancreatico-cholangio-duodenal fistula by the use of angiography and from the post-operative pathological findings.

Comparison of Double Balloon Enteroscopy and Capsule Endoscopy for Patients with Suspected Small Bowel Diseases / 대한소화기내시경학회지

BACKGROUND/AIMS: Double balloon enteroscopy (DBE) and capsule endoscopy (CE) are two new methods for evaluating small bowel diseases. However, the clinical relevance of these procedures remains to be uncovered. We investigated the diagnostic and therapeutic impact of DBE and CE for patients with suspected small bowel diseases. METHODS: We retrospectively reviewed the medical records of 60 patients who were examined by DBE or CE for suspected small bowel diseases between May 2003 and September 2005. The diagnostic yield and therapeutic impact were compared between the two groups. RESULTS: Thirty-five patients were examined by CE and 25 patients were examined by DBE. DBE showed abnormal findings in 20 patients (80%). CE detected abnormal findings in 23 patients (65.7%). The overall diagnostic yield was not different between the two groups (p=0.226). In the DBE group, therapeutic interventions were performed in 18 patients (72%). In the CE group, therapeutic interventions were performed in 7 patients (20%). The overall therapeutic impact showed a significant difference between the two procedures (p<0.001). CONCLUSIONS: Although there is no significant difference in the diagnostic yield between the two procedures, DBE appears to have a higher therapeutic yield than CE for patients with suspected small bowel diseases.

Clinical Characteristics and Risk Factors of Mortality among Severe Burn Patients with Isolation of Vancomycin-Resistant Enterococci / 감염과화학요법

BACKGROUND: Vancomycin-resistant enterococci (VRE) are multi-drug resistant organisms that have emerged as important nosocomial pathogens in recent years. Patients with burn injury are highly vulnerable to VRE infection. We evaluated the colonization and infection rate of VRE among severe burn patients. MATERIALS AND METHODS: We retrospectively reviewed VRE isolation in a tertiary hospital burn center from January 2000 to December 2003. We analyzed and compared the clinical characteristics of VRE colonized (isolated in rectal swab) and infected patients. We also analyzed the risk factors of mortality in VRE infection group by using univariate and multivariate analyses. RESULTS: VRE was isolated from 104 of severe burn patients. Mean percent of total body surface area of 104 patients was 45.43+/-22.15%. The most commonly isolated VRE was Enterococcus faecium (82.6%). The VRE infection rate of VRE colonization group was 19/93 (20.4%). There were no differences in clinical characteristics, underlying conditions, and isolates species between VRE colonization and infection groups. The mortality rate of VRE infection group was 40%. The risk factors for mortality were bacteremia (P=0.001) and mechanical ventilation (P=0.024) in univariate analysis. However, independent risk factor for death was only VRE bacteremia [odd ratio=32.803, 95% confidence interval (2.884, 373.129), P=0.005] in multivariate analysis. CONCLUSION: Significant portion of severe burn patients with VRE colonization could progress to VRE infection. Severe burn patients with VRE bacteremia have higher risk of death than patients without VRE bacteremia.

A Case of Disseminated Coccidioidomycosis Involving Lung and Skin in Patient with Diabetes Mellitus and Iatrogenic Cushings Syndrome / 결핵및호흡기질환

Coccidioidomycosis is caused by a dimorphous fungus, Coccidioides, which consists of two species, C. immitis and C. posadasii. Although these organisms are genetically distinct and do not exchange DNA, they appear identical phenotypically and the disease or immune response to the organisms is also identical. Coccidioides grows as a mycelium in the soil and is mainly found in Southwestern United States, northwestern Mexico, and Argentina. An infection usually results from inhaling the spores of the fungus in an endemic area. Patients with a localized infection and no risk factors for complications often require only a periodic reassessment to demonstrate the resolution of the self-limited process. However, patients with extensive spread of infection or high risk of complications as a result of immunosuppression or other preexisting factors require a variety of treatment strategies such as antifungal therapy, surgical debridement, or both. Korea is not endemic area of a coccidioidomycosis. We report a case of disseminated coccidioidomycosis involving the lung and skin, which was detected incidentally after sunburn in a 69 year-old Korean male with diabetes mellitus and iatrogenic Cushings syndrome, with a review of the relevant literature.

Clinical Characteristics in Patients with Vancomycin-Resistant Enterococci Colonization or Infection during 5 years in a Private General Hospital / 대한구급학회지

BACKGROUND: Vancomycin-resistant enterococci (VRE) is increasing rapidly through the world and is now a major cause of nosocomial infection. The transmission dynamics and factors contributing their dissemination are complex. We conducted a study to investigate clinical characteristics in patients with VRE colonization or infection during recent 5 years. METHODS: 154 cases that had the VRE infection or colonization from January 1, 2000 to April, 2004, were reviewed. We analyzed the risk factors of VRE infection and colonization and also compared various parameters contributing their dissemination between burn and non-burn patients with VRE. RESULTS: Total 212 strains of VRE were isolated from 154 patients. Of 212 strains of VRE, Enterococcus faecium (178 strains, 83.9%) were most common and followed by E. casseliflavus (28 strains, 13.2%), E. faecalis (5 strains, 2.4%) and E. gallinaum (1 strains, 0.5%). The most common place of VRE isolation was in burn intensive care unit (ICU), 95 cases (61.7%); 27 cases (17.5%) in general wards; 17 cases (11.0%) in surgical ICU; 15 cases (9.7%) in medical ICU. Compared with patients with VRE colonization, patients with VRE infection had older age, higher APACHE II scores and high death rate significantly. Then, VRE colonization were more common in burn patients while VRE infection were more common in non-burn patients. CONCLUSIONS: The findings from this study suggest that VRE infection are not uncommon among hospitalized patients. More strict infection control, close surveillance and judicious use of antibiotics may be warranted to prevent infection and transmission of VRE.

Clinical Characteristics and Risk Factors of Mortality among Severe Burn Patients with Isolation of Vancomycin-Resistant Enterococci / 감염과화학요법

BACKGROUND: Vancomycin-resistant enterococci (VRE) are multi-drug resistant organisms that have emerged as important nosocomial pathogens in recent years. Patients with burn injury are highly vulnerable to VRE infection. We evaluated the colonization and infection rate of VRE among severe burn patients. MATERIALS AND METHODS: We retrospectively reviewed VRE isolation in a tertiary hospital burn center from January 2000 to December 2003. We analyzed and compared the clinical characteristics of VRE colonized (isolated in rectal swab) and infected patients. We also analyzed the risk factors of mortality in VRE infection group by using univariate and multivariate analyses. RESULTS: VRE was isolated from 104 of severe burn patients. Mean percent of total body surface area of 104 patients was 45.43+/-22.15%. The most commonly isolated VRE was Enterococcus faecium (82.6%). The VRE infection rate of VRE colonization group was 19/93 (20.4%). There were no differences in clinical characteristics, underlying conditions, and isolates species between VRE colonization and infection groups. The mortality rate of VRE infection group was 40%. The risk factors for mortality were bacteremia (P=0.001) and mechanical ventilation (P=0.024) in univariate analysis. However, independent risk factor for death was only VRE bacteremia [odd ratio=32.803, 95% confidence interval (2.884, 373.129), P=0.005] in multivariate analysis. CONCLUSION: Significant portion of severe burn patients with VRE colonization could progress to VRE infection. Severe burn patients with VRE bacteremia have higher risk of death than patients without VRE bacteremia.

A case of paroxysmal atrial fibrillation induced by internal jugular venous catheterization for hemodialysis / 대한내과학회지

Right internal jugular vein is preferred for central venous catheter insertion because of fewer complications. However, insertion-related complications can occur such as arterial puncture, pneumothorax, and hemothorax. Arrhythmia can also occur, but it has been reported to temporarily occur only during guidewire insertion. We report a case of symptomatic paroxysmal atrial fibrillation induced by right internal jugular venous catheterization for hemodialysis. The chest X-ray taken after insertion of the catheter showed that the catheter was advanced too deeply into right atrium from an unusually lower puncture site. The atrial fibrillation persisted nearly 24 hours and was corrected by removal of the catheter. We experienced that paroxysmal atrial fibrillation can be complicated by central venous catheterization, and appropriate selection of puncture site and catheter length is important to avoid it.

One-lung Anesthetic Experience for Video-assisted Thoracoscopic Surgery in Two Children / 대한마취과학회지

Video-assisted thoracic surgery (VATS) has been increasingly used because of it is a less invasive procedure than the open thoracotomy. Neither commercially available double-lumen tubes nor the univent tube can be used in small children. An ordinary uncuffed tracheal tube was introduced into the main bronchus of the right lung. This technique proved to be a simple and effective method of isolating and ventilating the other lung. We describe our experience providing one-lung ventilation with ordinary endotracheal tube during VATS in two young children. (Korean J Anesthesiol 2001; 40: 824 ~ 828)