A Hepatic Lymphoma Mimicking Multiple Liver Metastases or an Intrahepatic Cholangiocarcinoma / 대한내과학회지

A primary hepatic lymphoma (PHL) is a rare malignancy; misdiagnosis and mistreatment are very common. We report the case of a 56-year-old female who presented with a 2-week history of upper abdominal pain. She exhibited no risk factors for hepatocellular carcinoma (HCC) and her serum tumor marker levels were normal. A computed tomography scan and gadolinium-enhanced magnetic resonance imaging of the liver revealed multiple liver masses, suggestive of multiple liver and lung metastases or an intrahepatic cholangiocarcinoma with lung metastasis. A diagnosis of PHL (a diffuse large B cell lymphoma) was confirmed by biopsy followed by immunohistochemistry. This case emphasizes that a PHL must be considered in the differential diagnosis of space-occupying liver lesions in patients with no risk factors for HCC and normal levels of serum tumor markers. It is notable that neither B cell lymphoma symptoms nor an elevated lactate dehydrogenase level were apparent in this case. We thus report a case of PHL mimicking multiple liver metastases or an intrahepatic cholangiocarcinoma, and we review the literature.

Acute Human Immunodeficiency Virus Syndrome Presenting with Hemophagocytic Lymphohistiocytosis

Hemophagocytic lymphohistiocytosis (HLH) has been described in patients with advanced stages of human immunodeficiency virus (HIV) infection, but rarely occurs during the seroconversion stage of acute HIV infection. We report a case of acute HIV syndrome that presented with virus-associated HLH. The patient recovered spontaneously without any immunomodulating therapy. This case suggests that acute HIV infection should be included in the differential diagnosis of HLH and indicates that HLH associated with acute HIV infection can have a favorable outcome.

The Efficacy and Safety of Linezolid for the Treatment of Suspected or Proven Gram Positive Skin and Soft Tissue Infections / 감염과화학요법

BACKGROUND: Linezolid, an oxazolidinone, has shown efficacy in the treatment of adults with nosocomial or community-acquired pneumonia, skin and soft tissue infections (SSTI), and infections due to methicillin-resistant Staphylococcus aureus. We have taken part in the study for evaluation of efficacy and safety of linezolid for the treatment of suspected or proven gram-positive SSTI in Asia. We sub-analyzed and reported the results of the study among Korean patients. MATERIALS AND METHODS: A total of 60 patients were enrolled in the study for evaluation of efficacy and safety of linezolid for the treatment of gram-positive SSTI at eight teaching hospitals in Korea. We investigated patients' medical history, physical examination and laboratory study. Patients were regularly followed up to evaluate clinical response, laboratory changes, and adverse event up to 4 weeks after treatment. When possible, we performed microbiological study before and after treatment. RESULTS: A total of 60 patients were enrolled. Average age of the patient was 50.9+/-15.3 years old with male to female ratio being 1.3:1. Cellulitis, open wound infection, skin abscess, and other clinical manifestations were observed in 47 (78.3%), 6 (10.0%), 2 (3.3%), and 5 (8.3%) patients, respectively. Forty two patients completed both follow-up and treatment and among them, treatment was successful in 38 patients (90.5%) and unsuccessful in 4 patients (9.5%). Microoranisms were isolated from seven patients and 14 isolates were documented; 11 S. aureus, 3 coagulase-negative staphylococcus. Among the seven patients, bacteria were eradicated in four patient and the organism proved to be colonization in three patients. The most frequent drug-related adverse events were gastrointestinal (21.7%), hematologic and biochemical (21.7%) and neurologic (3.3%), in decreasing order. Nausea (15%) was the most frequent symptom and there were no serious side effects related to linezolid. CONCLUSION: Linezolid was effective and safe in treatment of gram-positive SSTI.

The Efficacy and Safety of Linezolid for the Treatment of Suspected or Proven Gram Positive Skin and Soft Tissue Infections / 감염과화학요법

BACKGROUND: Linezolid, an oxazolidinone, has shown efficacy in the treatment of adults with nosocomial or community-acquired pneumonia, skin and soft tissue infections (SSTI), and infections due to methicillin-resistant Staphylococcus aureus. We have taken part in the study for evaluation of efficacy and safety of linezolid for the treatment of suspected or proven gram-positive SSTI in Asia. We sub-analyzed and reported the results of the study among Korean patients. MATERIALS AND METHODS: A total of 60 patients were enrolled in the study for evaluation of efficacy and safety of linezolid for the treatment of gram-positive SSTI at eight teaching hospitals in Korea. We investigated patients' medical history, physical examination and laboratory study. Patients were regularly followed up to evaluate clinical response, laboratory changes, and adverse event up to 4 weeks after treatment. When possible, we performed microbiological study before and after treatment. RESULTS: A total of 60 patients were enrolled. Average age of the patient was 50.9+/-15.3 years old with male to female ratio being 1.3:1. Cellulitis, open wound infection, skin abscess, and other clinical manifestations were observed in 47 (78.3%), 6 (10.0%), 2 (3.3%), and 5 (8.3%) patients, respectively. Forty two patients completed both follow-up and treatment and among them, treatment was successful in 38 patients (90.5%) and unsuccessful in 4 patients (9.5%). Microoranisms were isolated from seven patients and 14 isolates were documented; 11 S. aureus, 3 coagulase-negative staphylococcus. Among the seven patients, bacteria were eradicated in four patient and the organism proved to be colonization in three patients. The most frequent drug-related adverse events were gastrointestinal (21.7%), hematologic and biochemical (21.7%) and neurologic (3.3%), in decreasing order. Nausea (15%) was the most frequent symptom and there were no serious side effects related to linezolid. CONCLUSION: Linezolid was effective and safe in treatment of gram-positive SSTI.

Pulsed-Field Gel Electrophoresis (PFGE) Patterns and Antibiotypes for Sequential Isolates of Staphylococcus epidermidis from Blood Cultures / 감염과화학요법

BACKGROUND: The significance of Staphylococcus epidermidis positive blood cultures is difficult to determine, but repeated isolation of the same organism with the same genotype is suggestive of true bacteremia. MATERIALS AND METHODS: Two sequential isolates of S. epidermidis from blood cultures of the same twelve patients were genotyped by PFGE. The results were compared with those of antibiotyping and isolation time intervals between the two strains. RESULTS: The two sequential strains from each patient had identical PFGE patterns in 66.6% (8 of 12) of the patients and two different types in 33.3% (4 of 12) of the patients. Antibiotypes of the two isolates from the same patient were different in all 4 patients whose isolates had different PFGE patterns, and they were the same in 7 of 8 patients whose isolates had identical PFGE patterns:the PFGE results were in agreement with the antibiotyping for 91.7% (11/12) of patients. The isolation time interval between the two strains was or =5 days. CONCLUSION: These data showed that two consecutive isolates of S. epidermidis from blood cultures had different PFGE patterns in 33% of patients, suggesting a high prevalence of contamination. In the absence of genotyping measures, both antibiotype and isolation time interval can be alternative and useful tools for determining strain relatedness of sequential isolates of S. epidermidis from blood cultures.

Pulsed-Field Gel Electrophoresis (PFGE) Patterns and Antibiotypes for Sequential Isolates of Staphylococcus epidermidis from Blood Cultures / 감염과화학요법

BACKGROUND: The significance of Staphylococcus epidermidis positive blood cultures is difficult to determine, but repeated isolation of the same organism with the same genotype is suggestive of true bacteremia. MATERIALS AND METHODS: Two sequential isolates of S. epidermidis from blood cultures of the same twelve patients were genotyped by PFGE. The results were compared with those of antibiotyping and isolation time intervals between the two strains. RESULTS: The two sequential strains from each patient had identical PFGE patterns in 66.6% (8 of 12) of the patients and two different types in 33.3% (4 of 12) of the patients. Antibiotypes of the two isolates from the same patient were different in all 4 patients whose isolates had different PFGE patterns, and they were the same in 7 of 8 patients whose isolates had identical PFGE patterns:the PFGE results were in agreement with the antibiotyping for 91.7% (11/12) of patients. The isolation time interval between the two strains was or =5 days. CONCLUSION: These data showed that two consecutive isolates of S. epidermidis from blood cultures had different PFGE patterns in 33% of patients, suggesting a high prevalence of contamination. In the absence of genotyping measures, both antibiotype and isolation time interval can be alternative and useful tools for determining strain relatedness of sequential isolates of S. epidermidis from blood cultures.

In-Vitro Susceptibilities of Voriconazole Against Korean Clinical Aspergillus Isolates / 대한의진균학회지

BACKGROUND: Voriconazole is a potent new triazole antifungal agent expected to be particularly useful for the treatment of invasive aspergillosis. However, in vitro susceptibility of voriconazole for clinical strains of Aspergillus species isolated in Korea has not been fully surveyed. OBJECTIVE: We determined minimum inhibitory concentrations (MICs) of voriconazole for clinical Aspergillus isolates. METHODS: A total of 100 clinical isolates of Aspergillus species (40 A. fumigatus, 24 A. flavus, 17 A. niger, 17 A. terreus and 2 A. nidulans) was tested. In vitro voriconazole susceptibility testing was accomplished utilizing the National Committee for Clinical Laboratory Standards (NCCLS) broth microdilution method M38-A. MIC of voriconazole was determined using RPMI medium at 48 h of incubation. RESULTS: Among the 100 isolates of Aspergillus species tested, 98% were inhibited by or =2 microgram/mL were 0/40 (0%) in A. fumigatus, 1/24 (4%) in A. flavus, 1/17 (6%) in A. niger, 0/17 (0%) in A. terreus, and 0/2 (0%) in A. nidulans. CONCLUSION: These data demonstrate promising in-vitro activity of voriconazole against clinical strains of Aspergillus species isolated from Korean patients.

Pacemaker Lead Endocarditis Caused by Achromobacter xylosoxidans

We report the case of a 35-yr-old patient who presented with high fever and chills. He had undergone a patch closure of the ventricular septal defect 18 yr before. One year later, a VVI pacemaker was implanted via the right subclavian vein because of complete heart block. Nine years after that, a new VVI pacemaker with another right ventricular electrode was inserted controlaterally and the old pacing lead was abandoned. Trans-thoracic and trans-esophageal echocardiogram identified the pacemaker lead in the right ventricle (RV) attaching hyperechoic materials and also a fluttering round hyperechoic mass with a stalk in the RV outflow tract. Cultures in blood and pus from pacemaker lead grew Achromobacter xylosoxidans. A diagnosis of pacemaker lead endocarditis due to Achromobacter xylosoxidans was made. In this regards, the best treatment is an immediate removal of the entire pacing system and antimicrobial therapy.

Exfoliative Dermatitis and Toxic Hepatitis Associated with Occupational Exposure to Trichloroethylene / 대한산업의학회지

A 28-year-old male began working as a degreaser. The solvent used in the degreasing operation was trichloroethylene. Over the next month the man experienced fever, chills, and an erythematous skin rash and itching. At that time he had a marked elevation in his liver enzyme, with cholestasis. Over the next few days the rash persisted then peeled. There was an elevation of Ig E, and a positive patch test reaction to trichloroethylene. His dermatitis and hepatitis were considered to be mediated by a hypersensitivity mechanism.

Antifungal Susceptibilities and Distribution of Candida Species Recovered from Blood Cultures over an 8-Year Period / 대한진단검사의학회지

BACKGROUND: Nosocomial candidemia has increased over the past 2 decades. The rank order of occurrence and antifungal resistance profiles of the various species of Candida causing candidemia is important in establishing empiric treatment protocols. METHODS: We investigated antifungal susceptibilities and distribution of Candida species recovered from blood cultures over an 8-year period in Chonnam National University Hospital. The results obtained from the period 1994 through 1997 (period 1) were compared with those from the period 1998 through 2001 (period 2). Minimal inhibitory concentrations (MICs) of amphotericin B, fluconazole and itraconazole for each isolate were determined by the NCCLS broth microdilution method. RESULTS: During an 8-year period, 805 strains of Candida species were isolated from 290 patients. In period 1, the Candida species recovered most frequently from candidemic patients was C.albicans(29.5%), followed by C. parapsilosis (25.9%) and C. tropicalis (18.8%). In period 2, C. parapsilosis (31.5%) was the most common species, followed by C. albicans (23.6%), and C.glabrata (14.0%). These data, compared to those of period 1, indicate a variation in species distribution, with the proportions of C. glabrata increasing by 10.0% (Por=64 microgram/mL) and itraconazole (>or=1 microgram/mL) was observed more frequently in period 2 (8.0% and 20.9%, respectively) than in period 1 (2.0% and 7.0%, respectively)(P<0.05). CONCLUSIONS: These data showed that MICs of amphotericin B, fluconazole and itraconazole for each species did not change during the 8-year span, but azole resistant Candida species such as C. glabrata, increased in the latter four years (period 2).

Antifungal Susceptibilities and Distribution of Candida Species Recovered from Blood Cultures over an 8-Year Period / 대한진단검사의학회지

BACKGROUND: Nosocomial candidemia has increased over the past 2 decades. The rank order of occurrence and antifungal resistance profiles of the various species of Candida causing candidemia is important in establishing empiric treatment protocols. METHODS: We investigated antifungal susceptibilities and distribution of Candida species recovered from blood cultures over an 8-year period in Chonnam National University Hospital. The results obtained from the period 1994 through 1997 (period 1) were compared with those from the period 1998 through 2001 (period 2). Minimal inhibitory concentrations (MICs) of amphotericin B, fluconazole and itraconazole for each isolate were determined by the NCCLS broth microdilution method. RESULTS: During an 8-year period, 805 strains of Candida species were isolated from 290 patients. In period 1, the Candida species recovered most frequently from candidemic patients was C.albicans(29.5%), followed by C. parapsilosis (25.9%) and C. tropicalis (18.8%). In period 2, C. parapsilosis (31.5%) was the most common species, followed by C. albicans (23.6%), and C.glabrata (14.0%). These data, compared to those of period 1, indicate a variation in species distribution, with the proportions of C. glabrata increasing by 10.0% (Por=64 microgram/mL) and itraconazole (>or=1 microgram/mL) was observed more frequently in period 2 (8.0% and 20.9%, respectively) than in period 1 (2.0% and 7.0%, respectively)(P<0.05). CONCLUSIONS: These data showed that MICs of amphotericin B, fluconazole and itraconazole for each species did not change during the 8-year span, but azole resistant Candida species such as C. glabrata, increased in the latter four years (period 2).

Recently Occurring Adult Tetanus in Korea: Emphasis on Immunization and Awareness of Tetanus

Since a nationwide childhood vaccination with tetanus toxoid, tetanus has become a rare disease in Korea. However, we recently experienced 17 cases of adult tetanus in a university hospital during a 21-month period. Seventy percent of the patients were female, and the mean age was 63 yr (range, 29-87). The majority (88.2%) of the patients did not get primary vaccinations for tetanus and decennial tetanus-diph-theria toxoid booster. Most patients (88.2%), who sustained acute injury, did not seek medical care for their wounds or did not receive the prophylaxis for tetanus. Tetanus was found most frequently among farmers. Tetanus was diagnosed initially only in 53% of patients. The case-fatality ratio was 23.5%. These cases show that recently occurring tetanus in Korea is a disease, affecting the elderly and the female who may have a lower immunity against tetanus, and the farmers who are likely to be exposed to Clostridium tetani. In addition, diagnosis of tetanus is often delayed in area where cases are seen infrequently. Therefore, improved education among patients and physicians, emphasis of anti-tetanus immunization and awareness of tetanus respectively, may be essential for the prevention of disease and the reduction of its mortality.

Disseminated trichosporon beigelii infection / 대한내과학회지

No abstract available.

Granulocyte transfusions from G-CSF- and dexamethasone-stimulated healthy donors for treatment of patients with severe neutropenia-related infections / 대한내과학회지

BACKGROUND: Granulocyte transfusions have been used to treat severe, progressive infections in neutropenic patients who fail to respond to antimicrobial agents. Although corticosteroid or granulocyte colony-stimulating factor (G-CSF) were previously used separately to increase leukocyte counts in healthy donors, increasingly G-CSF and corticosteroids are used together, requiring the need to establish the efficacy of this mobilizing regime. METHODS: This prospective study evaluated the safety and efficacy of granulocyte transfusion therapy from donors stimulated with a combination of G-CSF and dexamethasone, in 27 patients with severe neutropenia-related infections. To mobilize granulocytes, healthy volunteer donors received G-CSF, 5 micro gram/kg subcutaneously 12-14 hr before leukapheresis, and dexamethasone, 3 mg/m2 intravenously 15 min before leukapheresis. RESULTS: Donor neutrophil counts were 5,723/micro L (range: 1,500~36,420) at baseline, 22,104/micro L (range: 9,700~41,300) before the injection of dexamethasone, 23,946/micro L (range: 10,900~42,100) immediately before leukapheresis, and 19,913/micro L (range: 9,100~36,300) after leukapheresis. Ninety-two leukapheresis procedures were performed with a mean yield of 7.88 10(10) granulocytes (range: 2.2~17.9 10(10)). The mobilizing agents were well tolerated in the donors. Of the patients, 16 (59.3%) showed favorable responses, whereas 11 (40.7%) had unfavorable responses. Adverse reactions to the therapy were arrhythmia in two patients (7.4%) and pulmonary edema in one patient (3.7%). Favorable responses were seen in 83.3, 76.9, and 45.5% of the patients from whom fungal, Gram-negative, and Gram-positive organisms were isolated, respectively. CONCLUSION: This study suggests that the combination of G-CSF and dexamethasone is an effective, well-tolerated regimen for mobilizing granulocytes from healthy donors, and that granulocyte transfusion therapy is useful for neutropenic patients, especially those with fungal or Gram-negative infections that are resistant to appropriate antimicrobial agents.

A case of fever of unknown origin after removal of hypothalamic tumor / 대한내과학회지

The preoptic area and anterior hypothalamus plays a pivotal role in body temperature regulation, and damage in this region causes hyperthermia. This hyperthermia is particularly troublesome because of the possibility that it may reflect an occult infectious process. We report a case of fever of unknown origin in a patient after removal of neoplasm involving the hypothalamus. A 29-year old man underwent craniotomy and removal of hypothalamic choroid meningioma. Seventy days after the removal of his tumor, his body temperature began to rise. But, there was no evidence of infection, inflammatory disease, metabolic disease, drug fever and recurred tumor. Repeated administration of antipyretic agent did not reduce body temperature. So, we considered that the elevated temperature had a central basis. The patient was treated with chlorpromazine in an attempt to lower his temperature. This drug reduced successfully his body temperature.

Infection Control Activities in Chonnam National University Hospital / 병원감염관리

No abstract available.

A Case of Maternal Tetanus in Korea

Tetanus is uncommon in Korea due to the introduction of vaccination programs and advances in public health. A case of maternal tetanus occurred on the 9 day postpartum in a 29-yr-old woman, who had not received a 10-yr-booster of tetanusdiphtheria toxoid after receiving the primary series of tetanus-toxoid-containing vaccine. There has hitherto been no reports on maternal tetanus in Korea. This case illustrates that tetanus remains a medical problem, principally among nonand underimmunized adults. The only way to fully prevent this disease is to ensure adequate immunization in all adults.

Colonization Rate, Risk Factor for Acquisition and Genetic Diversity of Vancomycin-Resistant Enterococci (VRE) Isolated from Rectal Culture of Patients in Intensvie Care Units from Ten Large Hospitals in Korea / 감염

BACKGROUND: VRE have become an emerging nosocomial pathogen in Korea, but there has not been nationwide study on the colonization of VRE among high risk groups of hospitalized patients. The purpose of this study was to determine the prevalence of rectal colonization of VRE among patients hospitalized in the intensive care unit (ICU), to study the risk factors for nosocomial acquisition of VRE among those patients, to define the genetic diversity of VRE strains in major hospitals in Korea. METHODS: Between January the 20th and 30th of 2000, a point surveillance study was conducted in the ICU of the ten large hospitals, which were located nationwide. Surveillance rectal swab cultures for detecting VRE were obtained among 214 patients admitted to the ICU during the study period. To isolate VRE, rectal swab cultures were performed on Enterococcosel(R) agar that containing 6 microgram/mL of vancomycin. Minimal inhibitory concentrations (MICs) of vancomycin and teicoplanin were determined by agar dilution method. For the genotyping of VRE isolates, the detection of vanA, vanB, vanC1 and vanC2 gene by polymerase chain reaction was done. Pulsed-field gel electrophoreis (PFGE) was used for elucidating the genetic relatedness of VRE isolates. To identify the risk factors for rectal VRE colonization, patients harboring VRE were compared to patients who were not colonized with this organism. RESULTS: The rectal colonization rate of VRE was variable from 9.7% to 51.9% according to hospital. 64 VRE strains which were isolated from 63 patients included 37 E. feacium. 26 E. gallinarum and 1 E. casseliflavus isolates. Therefore the colonization rate of clinically significant vanA type VRE was 17.3% (37/ 214). 37 E. feacium. 26 E. gallinarum and 1 E. casseliflavus isolates were presented as vanA, vanC1 and vanC2 genotypes, respectively. Risk factors for rectal VRE colonization included the presence of chronic illness, previous use of broad spectrum antibioitcs es-pecillay vancomycin, and prolonged stay in ICU. Various PFGE patterns are noted among vanA type VRE isolates, so individual acquisition of VRE during stay in the majority of ICUs were suggested. But there is some evidence of focal VRE spread within the ICU and between hospitals. CONCLUSION: This study demonstrated the high rectal colonization rate (17.3%) of clinically significant vanA type VRE among patients admitted to the ICUs of ten large hospitals located nation-widely. This study suggested that practicing HICPAC guidelines, restricted vancomycin usage and periodic surveillance cultures in patients with high risk factors are important in preventing the emergence and spread of VRE infection among ICU patients.

Molecular Typing of Candida parapsilosis Isolates from Patients and Healthcare Workers by Pulsed-Field Gel Electrophoresis / 감염

BACKGROUND: The epidemiology of Candida parapsilosis is still undefined and may involve sources such as hospital environment and hands of healthcare workers (HCWs). We performed molecular typing of C. parapsilosis isolates from intensive care unit (ICU) patients and to compare these with isolates from ICU HCWs. METHODS: A total of 57 C. parapsilosis strains including isolates from blood (n=20) and central venous catheter (n=14) of patients and isolates from hands of HCWs (n=23) were analyzed. All the isolates were collected from candidemic patients (n=20) and HCWs (n= 18) of two ICUs during January 1999 to December 2000. Pulsed-field gel electrophoresis (PFGE) analysis were performed by electrophoretic karyotyping and restriction endonuclease analysis of genomic DNA using SfiI. RESULTS: PFGE separated 57 isolates into 37 distinct types. For bloodstream isolates, a total of 18 different DNA types were identified among 20 isolates from 20 .patients: two strain types (K1 and K13) were shared by four isolates from four patients. The catheter strains from each patient exhibited the same PFGE pattern with bloodstream isolates. Of 23 strains from 18 HCWs, a total of 20 different DNA types were identified: 3 strain types shared by 6 isolates from 6 HCWs. Only one of the PFGE types of the HCWs was shared with patient isolates; an isolate with the same K13 pattern as isolates of two patients was found the hands of HCW. CONCLUSION: This suggest that although C. parapsilosis isolates have a high level of genetic diversity, nosocomial transmission may occur among ICU patients and HCWs via hands.

A Case of Toxoplasmic Encephalitis in an Advanced AIDS Patient / 감염

Toxoplasmic encephalitis (TE) is the most common cause of opportunistic central nervous system infection in advanced acquired immunodeficiency syndrome (AIDS) patients. The incidence of TE has fallen markedly after the availability of highly active antiretroviral therapy and cotrimoxazole chemoprophylaxis. TE linked to AIDS is a rare entity in Korea, but we must consider TE in the differential diagnosis of the opportunistic infections in AIDS patients. We report a case of toxoplasmic encephalitis in an advanced AIDS patient presenting as progressive right facial palsy.