Pheochromocytoma with Hypertensive Crisis Caused by Endoscopic Ultrasound-guided Tissue Sampling / 대한췌담도학회지

Although pheochromocytoma usually presents as a solid tumor, it can also present as a cystic lesion in the adrenal glands. Cystic lesions in the adrenal glands, along with hypertension, need attention to exclude pheochromocytoma. If ignored, they may lead to a hypertensive crisis with multi-organ failure. Proper preoperative preparation is important to prevent a hypertensive crisis during and after surgery. We report a case of pheochromocytoma with cystic degeneration that presented as a hypertensive crisis caused by endoscopic ultrasound-guided tissue sampling.

Nine Cases of Soft Tissue Infection Due to Non-Tuberculous Mycobacterium / 대한내과학회지

BACKGROUND/AIMS: Non-tuberculous Mycobacterium (NTM) infections usually result in chronic disease, and making a diagnosis is often difficult. Skin and soft tissue infections due to NTM are not common and are usually diagnosed relatively late. We investigated the clinical characteristics of nine cases of skin and soft tissue infections with NTM. METHODS: Nine patients with an NTM infection who were confirmed consecutively by skin and soft tissue and/or adjacent bone cultures at a teaching hospital between August 2006 and July 2013 were enrolled in this study. The demographics, clinical characteristics, underlying diseases, treatment, and prognosis between different NTM species were reviewed retrospectively. RESULTS: The most common NTM species causing a soft tissue infection was Mycobacterium abscessus (five patients, 55.6%). Common sites of infection were the knee and lumbar spine. Five patients (55.6%) had underlying diseases. Six patients (77.8%) were treated with combined surgical treatment (incision and drainage) plus antibiotics. The duration from symptom onset to diagnosis was long (77.7 +/- 44.6 days) due to inadequate microbiological evaluation and disregard for the clinical significance of the NTM culture. All patients were cured with treatment; however, the treatment duration was long (181.7 +/- 140.0 days). Procedure and cosmetic surgery were the most important risk factors for infection. CONCLUSIONS: The diagnosis of NTM skin and soft tissue infections tends to be delayed in a clinical setting. Therefore, a high index of suspicion for NTM infection in chronic localized soft tissue infections is essential for diagnosis. Mycobacterium abscessus appears to be the most common NTM species causing soft tissue infections.

Vitamin K-induced anaphylaxis

Vitamin K is a naturally-occurring vitamin used to treat certain coagulation disorders. Despite its frequent use, vitamin K causes allergic reactions very rarely. We report a case of anaphylaxis due to vitamin K (phytonadione) that occurred in a 20-year-old man who has undergone hemorrhoid bleeding. The patient developed immediate whole body urticaria, itching sensation, dyspnea and marked hypotension about 2 minutes after the intravenous administration of vitamin K (phytonadione) and tranexamic acid for the purpose of bleeding control. Skin prick test was performed with vitamin K and tranexamic acid. Vitamin K showed positive response in skin prick test, while tranexamic acid showed negative response in skin prick test and challenge test. To our knowledge, it is the first case report of vitamin K-induced anaphylaxis that is proven with skin test. This case suggests that vitamin K can elicit anaphylaxis and skin test may be helpful in the diagnosis of a suspected allergic response to vitamin K.

Septic Pulmonary Artery Thrombosis with Multiple Pulmonary Embolisms Caused by Candida tropicalis / 대한내과학회지

Septic pulmonary thromboembolism resulting from fungal infection is rare. A 32-year-old woman with acute paraquat intoxication was treated with high-dose intravenous steroid and cyclophosphamide pulse therapy. She presented with a prolonged fever, dyspnea, and multiple pneumonic infiltrations. Central venous catheterization was necessary for total parenteral nutrition. The response to antibiotic therapy was disappointing and Candida tropicalis was cultured in the blood repeatedly. Vegetations were found in the superior vena cava on echocardiography and both pulmonary arteries had massive thromboembolism on computed tomography (CT). Intravenous amphotericin B and anticoagulation therapy showed improvement. When patients with central venous catheters and recurrent fungemia present with dyspnea and fever, septic pulmonary thromboembolism and other disseminated infections, such as infective endocarditis or endophthalmitis, should be kept in mind.

Klebsiella pneumoniae as the Most Frequent Pathogen of Endogenous Endophthalmitis / 대한내과학회지

BACKGROUND/AIMS: Endogenous endophthalmitis (EE) is rare. However, the visual outcome of patients with EE is very poor. Many cases of EE caused by Gram-negative bacterial infections have recently been reported. This study was conducted to explore the most frequent pathogens, diagnosis, and treatment outcomes of EE. METHODS: A retrospective analysis was carried out in 23 patients diagnosed with EE through clinical manifestations and ophthalmic examinations in three hospitals between January 2000 and April 2011. Samples from 23 patients with EE were analyzed microbiologically. RESULTS: Pathogens were identified in 18 (78%) of the 23 blood, liver aspirate, and/or vitreous humor samples. Klebsiella pneumoniae was the most frequent organism (13/23, 57%). Abdomino-pelvic imaging (21/23, 91%) was performed to evaluate the primary site of infection. The most common primary infection was liver abscess (14/23, 61%). Despite administration of intravenous antibiotics and intravitreal injection, only six of 23 patients showed improvements in visual acuity. Thirteen (57%) experienced worse visual acuity. Four (17%) were eventually enucleated. CONCLUSIONS: In patients diagnosed with EE, abdomino-pelvic CT is required to exclude the presence of liver abscess. If a liver abscess is identified, percutaneous drainage should be considered. Considering the rapid progression and poor prognosis of EE, early diagnosis and immediate management are vital. We currently suggest that empiric antibiotics for treatment of EE should have activity against Gram-negative bacilli such as K. pneumoniae.

Methicillin-Sensitive Staphylococcus Aureus Tricuspid Valve Endocarditis in a Non-Drug-Addicted Patient without Predisposing Factors / 대한내과학회지

Staphylococcus aureus is a well-known pathogen involved inright-sided endocarditis with predisposing factors, and the clinical course may be acute and rapidly progressive. Intravenous drug abuse, pacemakers or central vascular catheters, and congenital heart diseases are well-known predisposing factors. However, right-sided endocarditis as a result of S. aureus infection is very rare in patients without these predisposing factors. Here, we report the case of a previously healthy 25-year-old male with native tricuspid valve infective endocarditis by methicillin-sensitive Staphylococcus aureus, complicating multiple septic pneumonia and septic pulmonary artery thrombosis. The patient was treated with antibiotics and surgical thromboembolectomy with tricuspid valve repair.

Methicillin-Sensitive Staphylococcus Aureus Tricuspid Valve Endocarditis in a Non-Drug-Addicted Patient without Predisposing Factors / 대한내과학회지

Staphylococcus aureus is a well-known pathogen involved inright-sided endocarditis with predisposing factors, and the clinical course may be acute and rapidly progressive. Intravenous drug abuse, pacemakers or central vascular catheters, and congenital heart diseases are well-known predisposing factors. However, right-sided endocarditis as a result of S. aureus infection is very rare in patients without these predisposing factors. Here, we report the case of a previously healthy 25-year-old male with native tricuspid valve infective endocarditis by methicillin-sensitive Staphylococcus aureus, complicating multiple septic pneumonia and septic pulmonary artery thrombosis. The patient was treated with antibiotics and surgical thromboembolectomy with tricuspid valve repair.

The Causes and Treatment Outcomes of 91 Patients with Adult Nosocomial Meningitis

BACKGROUND/AIMS: Frequent pathogens of nosocomial meningitis were investigated and the adequacy of empiric antibiotic therapy was assessed. Outcomes of nosocomial meningitis were also evaluated. METHODS: Ninety-one patients, who were diagnosed and treated for nosocomial meningitis at a single tertiary hospital in Daegu, Korea for 10 years, were included. Medical record and electronic laboratory data on the causative pathogens, antibiotics used, and outcomes were retrospectively investigated. RESULTS: Coagulase-negative Staphylococcus (40.9%) was the most common pathogen, followed by Acinetobacter (32.5%). Both were cultured as a single organism in cerebrospinal fluid (CSF). Seventy-eight patients (85.7%) had infections related to external ventricular drains (EVD). The most common empirical antibiotics were extended-spectrum beta-lactam antibiotics plus vancomycin (35/91, 38.6%). Of the 27 patients who had cultured Acinetobacter in CSF, 10 (37%) were given the wrong empirical antibiotic treatment. Seven of the 27 patients (26.9%) with cultured Acinetobacter died, and overall mortality of the 91 patients was 16.5%. In the multivariate analysis, the presence of combined septic shock (p < 0.001) and a persistent EVD state (p = 0.021) were associated with a poor prognosis. CONCLUSIONS: Acinetobacter is one of the leading pathogens of nosocomial meningitis and may lead to inadequate coverage of empiric antibiotic therapy due to increasing resistance. An EVD should be removed early in cases of suspected nosocomial meningitis, and carbapenem might be required for the poor treatment response.

Causes and Treatment Outcomes of Stevens-Johnson Syndrome and Toxic Epidermal Necrolysis in 82 Adult Patients

BACKGROUND/AIMS: Stevens-Johnson syndrome (SJS) and toxic epidermal necrolysis (TEN) are predominantly known as medication-induced diseases. However, at our institution, we have experienced more cases of non-drug-related SJS and TEN than expected. Therefore, we studied the difference between non-drug-related and drug-related SJS and TEN in terms of clinical characteristics and prognoses. METHODS: The etiologies, clinical characteristics, and treatment outcomes for 82 adult patients with SJS and TEN were retrospectively reviewed. RESULTS: A total of 71 patients (86.6%) were classified as having SJS, and the other 11 patients (13.4%) were classified as having TEN. Drug-related cases were more common (43, 52.4%) than non-drug-related cases (39, 47.6%). Anticonvulsants (12/82, 14.6%) and antibiotics (9/82, 11%) were the most common causative medications. Anemia (p = 0.017) and C-reactive protein of > or = 5 mg/dL (p = 0.026) were more common in the drug-related cases than in the non-drug-related cases. Intravenous steroid therapy was used as the main treatment regimen (70/82, 85.4%). Of the 82 patients, 8 (9.8%) died during the clinical course. A univariate analysis for mortality showed statistical significance for the following: kidney function abnormality, pneumonia, hemoglobin of < 10 g/dL, and combined underlying diseases. In a multivariate analysis, only pneumonia was statistically significant (odds ratio, 25.79; p = 0.009). CONCLUSIONS: Drugs were the most frequent cause of these diseases. However, non-drug-related causes also contributed to a significant proportion of cases. Physicians should keep this in mind when documenting patient history. In addition, early recognition and treatment may be important for better outcomes.

Two Cases of Cytomegalovirus Retinitis as a Manifestation of Good's Syndrome / 대한내과학회지

Good's syndrome (GS) is a rare cause of acquired combined B- and T-cell immunodeficiency in adults. GS is also known as a rare form of paraneoplastic syndrome of thymoma that may persist after thymectomy. Some reported GS cases have been related to various diseases as a result of humoral immunodeficiency, but no report to date has related GS to cytomegalovirus (CMV) retinitis in Korea. We report two cases of CMV retinitis as a manifestation of GS with severe cellular immunodeficiency. In the first case, a 61-year-old woman was diagnosed with GS manifesting as CMV retinitis combined with coincident pulmonary tuberculosis and soft-tissue tuberculosis. In the second case, a 56-year-old man had CMV retinitis and CMV pneumonia. Both patients had a history of thymoma and had received total thymectomies, and were diagnosed with GS a few years thereafter.