Malignant Hypertension with Pulmonary Alveolar Hemorrhage Needing Dialysis / 이화의대지

A 35-year-old man presented with progressive dyspnea and hemoptysis. His blood pressure was 230/140 mmHg and serum creatinine level was 20.13 mg/dL. Chest radiography and computed tomography revealed pulmonary hemorrhage. His renal function was low, thus emergent renal replacement therapy was required. Malignant hypertension and acute kidney injury were diagnosed, and antihypertensive therapy and hemodialysis started immediately. Renal biopsy was performed to examine the underlying disease. Typical pathological changes of malignant hypertension, fibrinoid necrosis of the afferent arterioles, and proliferative endoarteritis at the interlobular arteries were observed. His renal function improved gradually and pulmonary hemorrhage completely disappeared with administration of antihypertensive agents. Here, we report this rare case of malignant hypertension with pulmonary alveolar hemorrhage and speculate that the hemorrhage may be related to vascular injuries at the alveolar capillary level caused by malignant hypertension.

IgG4-Related Lung Disease without Elevation of Serum IgG4 Level: A Case Report / 결핵및호흡기질환

Since IgG4-related pancreatitis was first reported in 2001, IgG4-related disease has been identified in other organs such as salivary gland, gallbladder, thyroid, retroperitoneum and kidney; but lung invasion is rare. A 63-year-old man presented with hemoptysis at the pulmonary clinic and chest computed tomography revealed about 4.1 cm irregular shaped mass with spiculated margin at the left upper lobe. Despite no elevation of serum IgG4 level, he was finally diagnosed as IgG4-related lung disease by transthoracic needle biopsy. After treatment with oral glucocorticoids, hemoptysis disappeared and the size of lung mass was decreased.

A Case of Acute Kidney Injury in A 62 Year Old Man Who Took Atractylodes Macrocephala Koidzumi

The drug inducing tubulointerstitial nephritis is a crucial cause of acute kidney injury. Use of herbal plants in disease treatment is generally practiced in Korea. Although there are a small number of case reports, tubulointerstitial nephritis caused by taking Atractylodes macrocephala Koidzumi in human has never been reported. A 62-year-old man visited our hospital with symptoms of systemic edema accompanied by reduced urine volume and dyspnea after taking herbal plant 1 week ago. Chest radiographs showed both sided pleural effusion. Blood test results showed elevation of serum blood urea nitrogen and creatinine level and urine test results showed hematuria and proteinuria. Renal biopsy result showed evidence of tubulointerstitial nephritis by tubulitis and inflammatory cell expansion in the interstitium was observed. The patient's renal function recovered after administration of active renal replacement treatment and conservative therapy such as supplementation of fluid and electrolytes, and there was no disease recurrence for 1 year. Therefore, this case proved that Atractylodes macrocephala Koidzumi could cause acute kidney injury by the drug induced tubulointerstitial nephritis in human.

Agranulocytosis Induced by Ethambutol in a Patient with Pulmonary Tuberculosis / 결핵및호흡기질환

We report a case of agranulocytosis caused by ethambutol in a 79-year-old man with pulmonary tuberculosis. He was referred for fever and skin rash developed on 21th day after antituberculosis drugs (isoniazid, rifampicin, ethambutol, and pyrazinamide) intake. Complete blood count at the time of diagnosis of pulmonary tuberculosis was normal. On the seventh admission day, agranulocytosis was developed with absolute neutrophil count of 70/microL. We discontinued all antituberculosis drugs, and then treated with granulocyte colony-stimulating factor. Three days later, the number of white blood cell returned to normal. We administered isoniazid, pyrazinamide, and ethambutol in order with an interval. However, fever and skin rash developed again when adding ethambutol, so we discontinued ethambutol. After these symptoms disappeared, we added rifampicin and ethambutol in order with an interval. However after administering ethambutol, neutropenia developed, so we discontinued ethambutol again. He was cured with isoniazid, rifampicin, and pyrazinamide for 9 months.

Obstructive Jaundice Caused by Tuberculous Lymphadenopathies

Although pulmonary tuberculosis is known to be the most common type in tuberculosis, it actually can affect any organ system. However, abdominal type is very rare among the extra-pulmonary types, and obstructive jaundice caused by lymphadenopathies due to tuberculosis is especially uncommon manifestation even in endemic areas. Tuberculous lymphadenopathies can mimic lymphadenopathies by other metastatic tumors or lymphoma, thus early correct diagnosis is very important for avoiding unnecessary surgical interventions. Here, we reported two cases of obstructive jaundice caused by tuberculous lymphadenopathies. Both were treated with anti-tuberculosis medications and endoscopic retrograde biliary drainage without surgery.

Tracheal intubation with rocuronium using a "modified timing principle" / 대한마취과학회지

BACKGROUND: Rapid sequence induction (RSI) is indicated in various situations. Succinylcholine has been the muscle relaxant of choice for RSI, and rocuronium has become an alternative medicine for patients who cannot be administered succinylcholine for various reasons. Although rocuronium has the most rapid onset time among non-depolarizing muscle relaxants, the standard dose of rocuronium (0.6 mg/kg) takes 60 seconds to achieve appropriate muscle relaxation. We evaluated intubating conditions using the "modified timing principle" with rocuronium and succinylcholine. METHODS: In this prospective controlled blinded study, all patients received 1.5 microg/kg fentanyl intravenously with preoxygenation for 2 minutes and were randomized to receive 0.6 mg/kg rocuronium followed by 1.5 mg/kg propofol or 1.5 mg/kg propofol and 1.5 mg/kg succinylcholine. The rocuronium group was intubated just after confirming loss of consciousness, and the succinylcholine group was intubated 1 minute after injecting succinylcholine. Intubation condition, timing of events, and complications were recorded. RESULTS: All patients were successfully intubated in both groups. Apnea time of the rocuronium group (38.5 seconds) was significantly shorter than that in the succinylcholine group (100.7 seconds). No significant differences were observed in loss of consciousness time or intubation time. The succinylcholine group tended to show better intubation conditions, but no significant difference was observed. None of the patients complained awareness of the intubation procedure or had respiratory difficulty during a postoperative interview. CONCLUSIONS: The modified RSI with rocuronium showed shorter intubation sequence, acceptable intubation conditions, and a similar level of complications compared to those of conventional RSI with succinylcholine.