A Case of Primary Biliary Cirrhosis Mimicking Acute Hepatitis B in the Clinic, Republic of Korea / 가정의학회지

Primary biliary cirrhosis (PBC) is a slowly progressive cholestatic autoimmune liver disease characterized by progressive bile duct injury. The most common symptoms of this disease include fatigue and pruritus. The diagnosis of PBC is based on cholestatic biochemical liver tests, presence of antimitochondrial antibodies, and characteristic histological biopsy findings. We report a case of a patient with PBS, who was initially suspected to be in the window period of hepatitis B by a private doctor in a local clinic based on the detection of isolated immunoglobulin M antibody against hepatitis B core antigen. The presence of this antibody is the most useful index in diagnosing acute hepatitis B (+) by immunoserological test. The final diagnosis of the patient in Good Gang-An Hospital was PBC through additional tests. The patient is receiving outpatient treatment.

Retroperitoneal Schwannoma Mimicking an Adrenal Mass / 대한내과학회지

A schwannoma is a benign neoplasm originating from the Schwann cells of the neural sheath. The most common type of benign schwannomas is the acoustic neuroma presenting with deafness. We report a rare case of schwannoma mimicking an adrenal mass. A 66-year-old woman was diagnosed with an adrenal incidentaloma measuring 10 cm in length on a health checkup. The hormonal study revealed that the adrenal mass was non-functioning. Due to a high risk of adrenal malignancy, a retroperitoneal mass excision, distal pancreatectomy, splenectomy, wedge resection of stomach, and left adrenalectomy were conducted. The subsequent histopathologic examination revealed it to be a benign schwannoma.

Effect of low-dose valsartan on proteinuria in normotensive immunoglobulin A nephropathy with minimal proteinuria: a randomized trial

BACKGROUND/AIMS: Immunoglobulin A nephropathy (IgAN) is a generally progressive disease, even in patients with favorable prognostic features. In this study, we aimed to investigate the antiproteinuric effect and tolerability of low-dose valsartan (an angiotensin II receptor blocker) therapy in normotensive IgAN patients with minimal proteinuria of less than 0.5 to 1.0 g/day. METHODS: Normotensive IgAN patients, who had persistent proteinuria with a spot urine protein-to-creatinine ratio of 0.3 to 1.0 mg/mg creatinine, were recruited from five hospitals and randomly assigned to either 40 mg of valsartan as the low-dose group or 80 mg of valsartan as the regular-dose group. Clinical and laboratory data were collected at baseline, and at 4, 8, 12, and 24 weeks after valsartan therapy. RESULTS: Forty-three patients (low-dose group, n = 23; regular-dose group, n = 20) were enrolled in the study. Proteinuria decreased significantly not only in the regular-dose group but also in the low-dose group. The change in urine protein-to-creatinine ratio at week 24 was -41.3% +/- 26.1% (p < 0.001) in the regular-dose group and -21.1% +/- 45.1% (p = 0.005) in the low-dose group. In the low-dose group, blood pressure was constant throughout the study period, and there was no symptomatic hypotension. In the regular-dose group, blood pressure decreased at weeks 8 and 12. No significant change in glomerular filtration rate, serum creatinine level, or serum potassium level was observed during the study period. CONCLUSIONS: Our results suggest that low-dose valsartan can significantly reduce proteinuria without causing any intolerability in normotensive IgAN patients with minimal proteinuria.

Modified Peritoneal Dialysis Catheter Insertion: Comparison with a Conventional Method

PURPOSE: The conventional trocar and cannula method in peritoneal dialysis (PD) catheter insertion has its limitation in clinical setting. The aim of this study was to compare a modified method for percutaneous PD catheter insertion with the conventional method, and demonstrate advantages of the modified method. MATERIALS AND METHODS: Patients at a single center who had percutaneous PD catheters inserted by nephrologists from January 2006 until September 2012, using either a modified method (group M) or the conventional trocar and cannula method (group C), were retrospectively analyzed, in terms of baseline characteristics, complications experienced up to 3 months after the procedure, and the suitability of the procedure for patients. RESULTS: Group M included 82 subjects, while group C included 66 cases. The overall early complication rate in group M (1.2%) was significantly lower than that in group C (19.7%) (p<0.001). The catheter revision rate during timeframe for early complications was significantly lower in group M (0%) than in group C (6.1%) (p=0.024). When comparing Procedure time (1 h 3 min+/-16 min vs. 1 h 36 min+/-19 min, p<0.01), immediate post-procedural pain (2.43+/-1.80 vs. 3.14+/-2.07, p<0.05), and post-procedure days until ambulation (3.95+/-1.13 days vs. 6.17+/-1.34 days, p<0.01), group M was significantly lower than group C. There was no significant difference in total hospitalization period (14.71+/-7.05 days vs. 13.86+/-3.7 days). CONCLUSION: Our modified PD catheter insertion method shows its advantages in early complication rate, early complications revision rate, and the patients' conveniences.

Splenic Injury after Colonoscopy in Patient on Anti-Platelet Agents : A Case Study / 계명의대학술지

Colonoscopy is frequently used for lower GI tract screening tests. Although rare, splenic injury may develop in the high-risk patients on anticoagulants or antiplatelet agents. A 78-year-old female visited our hospital complaining of chest pain. She had taken antihyperlipidemic and antiplatelet agent with hyperlipidemia and 20%-stenosis in the left anterior descending artery. She was taken polypectomy after colonoscopy 4 years ago. The next day, after a follow-up colonoscopy for polypectomy, she complained epigastric and left upper abdominal discomfort. Pain intensity was not high, but next day, epigastric pain was increased, so coronary angiography was performed 2 days later using anticoagulants. Coronary angiography showed 40~50%-stenosis in the left anterior descending artery. Another antiplatelet agent was added. After 72 hours on colonoscopy, her pain was localized upper left abdominal area. Abdominal CT showed intracapsular bleeding in the spleen with a small amount of hemoperitoneum in the pelvis. Since her vital signs were stable, she was treated with conservative management. Her pain improved and discharged. One month later, she was taken Abdominal CT. CT showed the size of intracapsular fluid collection in the spleen was increased, but the whole fluid collection was liquidized. 2 weeks later, follow-up sonography showed the size of fluid collection conspicuously was reduced. The case reported herein is a splenic Injury after Colonoscopy in patient on antiplatelet agents.

A randomized crossover study of single biweekly administration of epoetin-alpha compared with darbepoetin-alpha in chronic kidney disease patients not receiving dialysis

BACKGROUND: Recent evidence demonstrates that high doses of epoetin-alpha (EPO-alpha) can be administrated at extended intervals, despite its relatively short serum half-life. However, no prospective randomized trials on the effects of extended dosing intervals of EPO-alpha compared with darbepoetin-alpha (DA-alpha) have been performed. This study was designed to investigate whether a single biweekly (Q2W) administration of a high dose of EPO-alpha is as effective as DA-alpha for anemia in chronic kidney disease (CKD) patients not receiving dialysis. METHODS: Sixty non-dialysis CKD patients were equally randomized to either Q2W subcutaneous EPO-alpha (10,000 unit) or DA-alpha (50microg) therapy groups for the first 6 weeks. After a 6-week washout period, the participants of the EPO-alpha and DA-alpha treatment groups switched to the alternate regimen for 6 weeks. The mean hemoglobin (Hb) levels after erythropoiesis stimulating agent (ESA) therapy and percentage change in Hb levels from baseline to the end of the study were analyzed. RESULTS: The mean Hb levels of postESA therapy increased significantly compared with those of preESA therapy in both ESA regimens. The percentage increase in Hb levels and erythropoietin resistance index did not show a significant difference between the different ESA regimens. No difference was observed between the regimens regarding mean Hb levels after ESA therapy. Additionally, there were no serious adverse effects leading to withdrawal from treatment. CONCLUSION: Biweekly high doses of EPO-alpha therapy may be equally as effective as Q2W DA-alpha therapy in maintaining target Hb levels in non-dialysis CKD patients.

Simultaneous Development of ST-Segment Elevation Myocardial Infarction and Pulmonary Embolism in an Healthy Elderly Woman

A 73-year-old woman who presented with chest discomfort visited the emergency room. The 12-lead electrocardiography showed ST-segment elevation in II, III, and lead augmented vector foot. Emergent coronary angiography revealed a thrombus in the distal right coronary artery. Percutaneous coronary angioplasty with a stent was performed. After the procedure, persistent dyspnea occurred. Her chest computed tomography (CT) showed occlusion of the bilateral pulmonary artery. We could not find a source for the embolization or a hypercoagulable state. We started a course of dual antiplatelets with oral anticoagulants. Pulmonary embolism was resolved at follow-up chest CT scan. Aspirin, clopidogrel and warfarin were given for 6 months. The patient is doing well now 1 year after the episode.

A Case of PICOLIGHT Powder Induced Thermal Injury of the Gastric Mucosa

There are many reports about causes of corrosive agents such as acids and alkaline and occasionally hot food in either liquid or solid forms as causes of upper gastrointestinal mucosal injury. However, there have been no reports on bowel preparation solutions as a cause of upper gastrointestinal injury. We describe a case of bowel preparation solution (PICOLIGHT powder) induced thermal injury of the gastric mucosa with a review of the literature.

Colonic Diverticulitis Complicating Colo-ovarian Fistula and Tuboovarian Abscess Formation in on Old Woman

The inflammation of colonic diverticulum, diverticulitis, is occasionally accompanied by several complications, such as bleeding, bowel obstruction, fistula and abscess formation. Both colo-ovarian fistula and tuboovarian abscess formation, as complications of diverticulitis, are rare. Here, we report a case of colonic diverticulitis which ultimately resulted in colo-ovarian fistula and tuboovarian abscess formation. A 76-year-old female was presented with lower abdominal pain, diarrhea and intermittent hematochezia for about 1 month. According to the abdominal computed tomography, tuboovarian abscess was shown to adhere to the inflamed sigmoid diverticulum. Sigmoidoscopy revealed pus flowing from the opening of the diverticulum at the sigmoid colon. Hence, the patient underwent oophorosalpingectomy and low anterior resection. Thereafter, she was treated with bowel rest and broad spectrum antibiotics, and finally recovered. Although rare, colonic diverticulitis may result in colo-ovarian fistula causing tuboovarian abscess formation in postmenopausal patients. Early recognition of the condition and appropriate treatment, including surgery and antibiotics, are necessary in order to achieve full recovery from complicated diverticulitis.

Newly Diagnosed Diabetes Mellitus With Pancreatic Cancer Manifested as Hyperglycemic Hyperosmolar State

Here, we report a case of newly diagnosed diabetes, with concurrent pancreatic cancer manifested as hyperglycemic crisis, and aggravated by urinary tract infection. We summarize the initial clinical manifestations and pertinent laboratory, radiologic, and clinical findings in an elderly patient with hyperglycemic emergency. A review of the documents involving pancreatic tumors and hyperglycemic hyperosmolar state, which is an acute complication of diabetes mellitus, is presented. In the absence of other identifiable conditions, it is reasonable to speculate that some factor (or factors) produced by the tumor had a role in the metabolic decompensation. In addition, this discussion should be more carefully considered in the aged people group.

A Case of Immunoglobulin A Nephropathy in a Patient with Kimura's Disease / 영남의대학술지

Kimura's disease is an angiolymphoid-proliferative disorder that manifests with benign subcutaneous swelling predominantly in the head and the neck. Kidney involvement, including proteinuria, occurs in 12-16% of patients with the disease, and 60-78% of such cases is nephrotic syndrome. Reported etiologies of nephrotic syndrome in Kimura's disease include membranous glomerulonephritis, mesangial proliferative glomerulonephritis, minimal-change disease, focal segmental glomerulosclerosis, diffuse proliferative glomerulonephritis and immunoglobulin A (IgA) nephropathy. There have been only two case reports of IgA nephropathy in Kimura's disease, in 1998. In this report, we present a third case of IgA nephropathy associated with Kimura's disease.

Treatment of a Periesophageal Abscess with Endoscopic Ultrasonography-Guided Drainage and Antibiotics: A Case Report / 대한내과학회지

In periesophageal abscesses, the inflammatory reaction occurs on the surrounding esophagus and pus cavity formation accompanies complications of endoscopic procedures or esophageal perforation induced by sharp foreign bodies. Here, we report the treatment of a periesophageal abscess with endoscopic ultrasonography-guided incision and drainage, and broad-spectrum antibiotics. Follow-up endoscopy revealed no lesion other than the incision scar. We report a case of periesophageal abscess that was treated non-surgically and review the relevant literature.

Two Cases of the Norwegian Scabies-Infested Patients with Chronic Disease in Elderly Care Unit

The scabies mite is an ectoparasite, which is able to infest humans. The incidence of scabies decreased during the past 20 years in Korea. However, the incidence is likely to increase again, and may be delayed or missed diagnosis recently. Its clinical presentation is typical, although in a host with compromised immune system, like the mentally retarded and elderly patients, the clinical presentation may be altered. Because a delay in diagnosis may induce rapid spread of the scabies mite, immediate diagnosis and treatment are necessary. We report two cases of scabies in elderly patients from different nursing homes. These patients were transferred to our center for treatment of pneumonia and chronic renal disease. They revealed pruritus and skin rashes after the treatment of further underlying diseases. We consulted to a dermatologist because of worsening symptoms, despite an application of medication with antihistamine and topical steroid, scabies was diagnosed. The symptom improved with topical 1% gamma-benzene hexachloride, an effective scabies drug. We suggest that geriatrists should suspect scabies who presents with pruritus that is persistent or resistant to conventional treatment, especially patients transferred from nursing homes.

Non-Dipper Status and Left Ventricular Hypertrophy as Predictors of Incident Chronic Kidney Disease

We have hypothesized that non-dipper status and left ventricular hypertrophy (LVH) are associated with the development of chronic kidney disease (CKD) in non-diabetic hypertensive patients. This study included 102 patients with an estimated glomerular filtration rate (eGFR) > or = 60 mL/min/1.73 m2. Ambulatory blood pressure monitoring and echocardiography were performed at the beginning of the study, and the serum creatinine levels were followed. During the average follow-up period of 51 months, CKD developed in 11 patients. There was a significant difference in the incidence of CKD between dippers and non-dippers (5.0% vs 19.0%, P < 0.05). Compared to patients without CKD, patients with incident CKD had a higher urine albumin/creatinine ratio (52.3 +/- 58.6 mg/g vs 17.8 +/- 29.3 mg/g, P < 0.01), non-dipper status (72.7% vs 37.4%, P < 0.05), the presence of LVH (27.3% vs 5.5%, P < 0.05), and a lower serum HDL-cholesterol level (41.7 +/- 8.3 mg/dL vs 50.4 +/- 12.4 mg/dL, P < 0.05). Based on multivariate Cox regression analysis, non-dipper status and the presence of LVH were independent predictors of incident CKD. These findings suggest that non-dipper status and LVH may be the therapeutic targets for preventing the development of CKD in non-diabetic hypertensive patients.

Death of a Patient with Turner Syndrome Caused by Arotic Dissection and Rupture after Hemodialysis / 대한신장학회지

The main cause of death in hemodialysis patients is cardiovascular disease. Aortic dissection with rupture is one of the most life threatening cardiovascular diseases. The risk of developing aortic dissection can be increased by renal failure or hemodialysis and the morbidity also increases in Turner syndrome. Here, we report a case of Turner syndrome patient who died from ruptured aortic dissection after hemodialysis, and review relevant literature. A 59 year-old female presented to the emergency department complaining of severe dyspnea and general weakness. Six months ago, she had undergone an operation at another hospital due to horseshoe kidney and staghorn calculus. After the operation, acute renal failure developed, so she received hemodialysis. The chest x-ray image taken at the time of admission showed mediastinal widening compared to image taken 6 months ago. Aortic dissection was diagnosed by chest computer tomograph. Chromosomal analysis was performed and the study revealed the mosaicism of Turner syndrome (45,X/ 46,XX). The genetic defect, renal failure and especially hemodialysis were thought as important risk factors in the development of aortic dissection in this patient. Although storongly advised to have emergency operation, the patient only wanted conservative management. Two months later, the patient died from aorta rupture.

A Case of Behcet Disease with Intestinal Involvement in an Elderly Patient

Behcet disease is a multisystemic disorder characterized by a chronic relapsing triple symptom complex of recurrent oral ulceration, genital ulceration, and ocular inflammation. The onset of Behcet disease is rare in old age as is whole colon involvement. We recently saw a 78-year-old female patient examined to have intestinal Behcet disease with diffuse colon ulcers. She was admitted due to multiple oral ulcers, genital ulcers, low abdominal pain, and hematochezia. Colonoscopy showed multiple well-demarcated, large, deep, bleeding ulcers from the cecum into the descending colon. The patient was diagnosed with Behcet disease and treated with steroid, colchicine, and mesalazine. This paper describes a case of Behcet disease with unusual intestinal distribution.

A Case of Successful Colonoscopic Treatment of Colonic Obstruction Caused by Phytobezoar

A phytobezoar is the most common type of bezoar, which is a gastrointestinal mass composed of vegetable. A persimmon is a common cause of a phytobezoar. The majority of bezoars are found in the stomach, with the small intestine being the next most commonly involved site. The colon is a rare site for a bezoar. Recently, we experienced a colonic bezoar that caused colonic obstruction in a 66-year-old female patient who took persimmons regularly. The patient came to the hospital because of abdominal pain and distension. To differentiate a tumor or other problems that can cause intestinal obstruction, we performed an abdominal computed tomography scan and found an ovoid intraluminal mass with a mottled gas pattern in the distal descending colon. A large impacted bezoar was seen in the sigmoid colon, which was completely obstructed, and it was successfully removed by using colonoscopy.

A Case of Stevens-Johnson Syndrome with Acute Renal Failure Induced by Rhus-Chicken Ingestion / 대한내과학회지

Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN) are severe, diffuse mucocutaneous reactions that can be elicited by drugs, infection, malignancy, and herbal supplements. A wide variety of mucocutaneous events, such as systemic contact dermatitis, have been reported to be elicited by Rhus chicken, although cases of SJS and TEN are rare. Here, we present a case of SJS caused by Rhus-chicken ingestion. A 48-year-old man who wanted to improve his health and treat a gastrointestinal problem ingested Rhus chicken in the traditional manner. Twenty-four hours later, he developed a multiple erythematous maculopapular skin rash with vesicles and bullaes on 30% of the body surface and multiple erosions on the lips. He was diagnosed with SJS/TEN and showed characteristic clinical findings induced by Rhus chicken. After the patient stopped Rhus-chicken ingestion and received methylprednisolone and antibiotics, his symptoms, signs, and laboratory findings improved. With this case, we emphasize that SJS and TEN can occur after ingesting Rhus chicken, although the incidence is very low.

A Case of Hyperkalemic Periodic Paralysis Induced by Diabetic Nephropathy / 대한내과학회지

Hyperkalemic periodic paralysis is characterized by episodic flaccid paralysis of the skeletal muscles due to an increase in serum potassium concentrations. Primary hyperkalemic periodic paralysis is caused by point mutations in SCN4A, encoding a voltage-gated skeletal muscle sodium channel. However, hyperkalemia-related diseases, such as renal failure, adrenal insufficiency, hypoaldosteronism, and chronic diuretic use, can induce secondary hyperkalemic periodic paralysis. Diagnosis of this disease is based on clinical features, nerve conduction studies, and a DNA sequence analysis. In cases of diagnostic uncertainty, a provocation test can be used to ensure the correct diagnosis. Here, we report a case of secondary hyperkalemic periodic paralysis with hyperkalemia that was induced by diabetic nephropathy, and review the relevant literature.

Serum Adiponectin as a Predictor for Cardiovascular Outcomes in Non-Diabetic End-Stage Renal Disease Patients / 대한신장학회지

PURPOSE: Adiponectin (ADPN) has been known to protect against cardiovascular disease (CVD) in metabolic syndrome with normal renal function for its anti-inflammatory and anti-atherogenic property. However, it is still unclear whether ADPN is associated with cardiovascular outcomes in end-stage renal disease (ESRD) patients. METHODS: This study included 80 non-diabetic ESRD patients [mean age, 52.8+/-13.7 years; dialysis duration, 67.1+/-52.0 months; hemodialysis (HD), 35 pts; peritoneal dialysis (PD), 45 pts] who survived for more than 3 months after the start of dialysis, and serum ADPN levels were measured at the beginning of the study. We conducted a longitudinal follow-up to evaluate the association of serum ADPN level with cardiovascular outcomes for 29.3+/-6.7 months. RESULTS: ADPN was inversely correlated with fasting serum insulin (r=-0.309, p=0.006) and HOMA-IR (r=-0.321, p=0.004) in ESRD patients. In a multiple linear regression analysis adjusted for age, gender, waist to hip ratio (WHR), and HDL-cholesterol, HOMA-IR (beta=-0.880, p=0.041) was an independent factor associated with serum ADPN level. Kaplan-Meier analysis revealed that patients with higher ADPN levels (> or =15.8 microgram/mL) had a significantly higher survival rate compared with lowers (<15.8 microgram/mL) (p=0.032). Cox proportional hazard model adjusted for age, WHR, creatinine, CRP, and previous CVD history revealed that serum ADPN level (HR, 0.899; 95% CI, 0.818-0.987; p=0.026) was an independent determinant of cardiovascular outcomes. CONCLUSION: These findings suggest that lower ADPN levels independently predict cardiovascular events in non-diabetic ESRD patients.