Pancreatic Neuroendocrine Tumor Presenting with Arthritis and Panniculitis

Pancreatic neoplasm is complicated and can be preceded by extra-pancreatic manifestations, such as cutaneous and musculoskeletal symptoms. Awareness of these associations is important for timely diagnosis and appropriate treatment. We report a case of pancreatic neuroendocrine tumor (NET) presenting with arthritis and panniculitis. The patient had a two month history of right knee pain and subcutaneous nodules in both legs. Synovial fluid analysis from the right knee joint revealed a mildly increased white blood cell count without crystallization. A skin biopsy of a subcutaneous nodule revealed lobular panniculitis. The initial treatment with empirical antibiotics did not alleviate the symptoms; however, the right knee arthritis and skin nodules improved with steroid treatment. On the eighth day of hospitalization, the patient complained of abdominal discomfort. Abdominopelvic computed tomography scanning revealed a 14-cm sized pancreatic mass with peritoneal metastasis. Percutaneous needle biopsy confirmed the diagnosis of pancreatic NET.

Severe Scrub Typhus with Hemophagocytic Lymphohistiocytosis Occurring in Summer / 대한내과학회지

In Korea, scrub typhus usually occurs in October and November. Hemophagocytic lymphohistiocytosis (HLH) is a distinct clinical entity characterized by a high fever, pancytopenia, hepatosplenomegaly, histiocyte proliferation, and hemophagocytosis. We encountered a summertime case of severe scrub typhus presenting as HLH. A 49-year-old female complained of abdominal pain and fever 3 days in duration. On hospital day 3 she was transferred to the intensive care unit because of clinical deterioration accompanied by severe sepsis. As an eschar was evident on the right shoulder, we commenced doxycycline. Her condition improved dramatically and she was discharged on day 14. Although the indirect immunofluorescence antibody test (IFA) for Orientia tsutsugamushi was negative on admission, a repeat IFA test was positive; the antibody titer was 1:5,120 on hospital day 10. Scrub typhus should be considered during differential diagnosis in a patient with severe sepsis in any season except the fall.

Efficacy of tenofovir-based rescue therapy for chronic hepatitis B patients with resistance to lamivudine and entecavir

BACKGROUND/AIMS: Tenofovir disoproxil fumarate (TDF) monotherapy for 48 weeks provided a virological response comparable to that of TDF and entecavir (ETV) combination therapy in patients infected with ETV-resistant hepatitis B virus (HBV). Little long-term data in routine clinical practice are available regarding the optimal treatment of patients with ETV-resistant HBV. METHODS: We investigated the long-term antiviral efficacy of combination therapy of TDF+lamivudine (LAM) or TDF+ETV compared to that of TDF monotherapy in 73 patients with resistance to both LAM and ETV. RESULTS: Patients were treated with TDF monotherapy (n=12), TDF+LAM (n=19), or TDF+ETV (n=42) for more than 6 months. The median duration of TDF-based rescue therapy was 37 months. Virologic response (VR) was found in 63 patients (86.3%). The rates of VR among the three groups (TDF monotherapy, TDF+LAM, and TDF+ETV) were not statistically different (log-rank P=0.200) at 12 months (59.3%, 78.9%, and 51.8%, respectively) or at 24 months (88.4%, 94.7%, and 84.2%). In addition, treatment efficacy of TDF-based combination or TDF monotherapy was not statistically different with ETV-resistant strains or exposure to other antiviral agents. In multivariate analysis, only lower baseline HBV DNA level was an independent predictor for VR (hazard ratio, 0.723; 95% confidence interval, 0.627-0.834; P<0.001). CONCLUSIONS: TDF monotherapy was as effective as combination therapy of TDF+LAM or TDF+ETV in maintaining long-term viral suppression in chronic hepatitis B patients with resistance to both LAM and ETV. HBV DNA level at the start of TDF rescue therapy was the only independent predictor of subsequent VR.

A Case of Perimembranous Ventricular Septal Defect Associated with Sinus of Valsalva Aneurysm Mimicking Membranous Septal Aneurysm

Sinus of Valsalva aneurysms are rare. Sinus of Valsalva aneurysms are frequently associated with ventricular septal defect (VSD) and aortic regurgitation. They often remain asymptomatic until abruptly presenting with acute chest pain and heart failure secondary to rupture. Here, we describe a case of 20-year-old man who presented with chest pain with a history of VSD. Initial work-up concluded that the patient had VSD associated membranous septal aneurysm. Four years later, the patient presented with symptoms of heart failure. Work-up showed that the ruptured sinus of Valsalva aneurysm was the cause of symptoms. Due to its close proximity to the aortic annulus, sinus of Valsalva aneurysm should be differentiated from membranous septal aneurysm.

Disseminated Scedosporium apiospermum Infection Induced from Aspiration Pneumonia after Near-Drowning / 결핵및호흡기질환

Scedosporium apiospermum, the anamorph of Pseudallescheria boydii, is a ubiquitous saprophytic fungus. S. apiospermum can cause life-threatening infections usually in immunocompromised patients or after near-drowning incidents. Here, we report the first case of disseminated infection caused by S. apiospermum after near-drowning in Korea. A 44-year-old healthy man developed aspiration pneumonia, followed by multiple brain abscesses, and endopthalmitis, after a near-drowning incident in a septic tank. S. apiospermum infection was diagnosed on the 33rd day after the incident had occurred. The patient died from the progressive renal failure 255 days after incident, although he had been treated with voriconazole.

A case of aortoduodenal fistula and vertebral erosion caused by an abdominal aortic aneurysm / 대한내과학회지

A primary aortoenteric fistula is an uncommon complication of an abdominal aortic aneurysm, but can be fatal due to the high risk of massive bleeding and sepsis. Rarely, an abdominal aortic aneurysm can cause vertebral erosion. We report uncommon complications of an abdominal aortic aneurysm that caused an aortoduodenal fistula and lumbar vertebral erosion. To our knowledge, this is the first case of an abdominal aortic aneurysm complicated by an aortoduodenal fistula and vertebral erosion simultaneously.

Deep Vein as a Graft Conduit: 2 case reports / 대한흉부외과학회지

The ideal graft requires acceptable size, less tissue toxicity, resistance to infection, and long-term durability. Great saphenous veins are gaining popularity as acceptable graft conduits, but they require time to grow in caliber. We report 2 cases of graft bypass and reconstruction using superficial femoral veins to acheive immediate high-flow patency.

Laparoscopic Treatment of Mesenteric Castleman's Disease

Castleman's disease (CD) is an uncommon lymphoproliferative disorder of unknown origin. There are two histological types: hyaline-vascular type and plasma cell type. CD is usually located in the mediastinum, but may be seen in any site including the neck, axilla, mesentery, and retroperitoneum. A 52-year-old male complained of vague lower abdominal pain. There was no palpable mass and all laboratory data showed nonspecific findings. Abdominal computed tomography scan showed a solitary homogenous, well-defined mass in the mesentery. The laparoscopic complete resection was performed without complications. Histologic examination of resected lesion revealed the hyaline-vascular type of CD. In the hyaline-vascular type of CD, laparoscopic approach constitutes a complete treatment. We present here the case of laparoscopic treatment of isolated mesenteric CD.

Analysis of the Relationship between Bilaterality and Other Clinicopathological Factors in Papillary Thyroid Carcinoma / 대한내분비외과학회지

PURPOSE: The extent of the initial surgical treatment for patients with papillary thyroid carcinoma (PTC) is controversial. Many surgeons think thattotal thyroidectomy is the most optimal treatment for PTC because of its potential bilaterality. Therefore, bilaterality is an important factor for determining the extent of surgical resection. The aim of this retrospective study is to analyze the relationship between tumor bilaterality and the other clinicopathological factors. METHODS: We conducted a retrospective analysis of 140 patients with PTC and who underwent total thyroidectomy with central lymph node dissection from January to December 2007 at our institution. RESULTS: Among 140 patients, 50 patients (35.7%) had PTC in the bilateral lobes. Of these 50 patients, only 17 patients (34.0%) were operated on under the preoperative diagnosis of bilateral PTC. Two factors, 1) presence of the capsular invasion (P=0.007) and 2) an increase of the tumor size (P=0.023), were statistically correlated with bilaterality. There were no significant associations between bilaterality and the other clinicopathological factors,including age, extrathyroidal invasion and lymph node metastasis. CONCLUSION: For the surgical care of PTC, bilaterality must always be considered even though the tumor is diagnosed preoperatively as unilateral PTC. Furthermore, thorough preoperative evaluation is mandatory if unilateral lobectomy is regarded as a therapeutic option for PTC patients.

Analysis of the Relationship between Central Cervical Lymph Node Metastasis from Papillary Thyroid Carcinoma and the Associated Factors according to the Tumor Size

PURPOSE: The aim of this study was to analyze the relationship between central lymph node metastasis and the associated factors in patients with papillary thyroid carcinoma (PTC) according to the tumor size, and we wanted to determine an appropriate treatment for PTC. METHODS: From June 2005 to May 2007, 218 patients with PTC underwent total thyroidectomy or lobectomy, and they also received central lymph node dissection at our institution. The patients were divided into three groups: group 1 (tumor 10 mm). We retrospectively reviewed these patients to analyze the relationship between tumor size and the clinicopathological characteristics, including age, gender, lymph node metastasis, extrathyroidal extension, capsular invasion and lymphovascular invasion. RESULTS: There were 47 (21.6%) patients in group 1, 101 (46.3%) patients in group 2 and 70 (32.1%) patients in group 3. The tumor size was closely correlated with the presence of extrathyroidal extension, capsular invasion and lymph node metastasis (P<0.001). Lymph node metastasis was not only closely correlated with tumor size, but it was also significantly associated with extrathyroidal extension, capsular invasion and lymphovascular invasion (P<0.05). CONCLUSION: Our study confirmed that some factors, including central lymph node metastasis, capsular invasion and extrathyroidal extension, were frequently observed in patients with papillary thyroid microcarcinoma (PTMC), and central lymph node metastasis was related to tumor size, extrathyroidal extension, capsular invasion and lymphovascular invasion. Therefore, routine central lymph node dissection is recommended during the initial surgery for patients with PTMC.

Isolated Traumatic Gallbladder Rupture

Gallbladder (GB) injuries after blunt abdominal trauma are uncommon. An isolated blunt GB injury is extremely rare, due to the anatomic location of the GB that is protected by the liver, intestines, omentum and ribs. A GB injury follows a vague and insidious clinical course, and therefore GB injuries are commonly undiagnosed until an exploratory laparotomy is performed. Early diagnosis is important, as trauma to the GB should be treated surgically and a delay in treatment can result in considerable mortality and morbidity. We encountered a patient who was diagnosed with a GB rupture based on computed tomography that showed a hemoperitoneum, high-density material in the GB lumen and a leakage of contrast material. The patient underwent an exploratory laparotomy. We report a case of isolated GB rupture after blunt abdominal trauma.

Postanal Retrieval and Anastomosis in Laparoscopic Rectal Surgery: Report of 3 Cases

Laparoscopic surgery is popular and widely accepted method for colorectal cancer today. Especially in rectal cancer, laparoscopic TME made surgery safe and feasible with good outcome. But there are still some limits and difficulties in resection and anastomosis of low rectal cancer. We combined laparoscopic TME and posterior approach. Surgery was performed in three low rectal cancer patients. They were prepared in supine position and laparoscopic TME to pelvic floor muscles was performed. After changing the patient to Jack-knife position, post-anal median incision (between the external sphincter and coccyx) and distal rectal resection was done. Through this surgical window, proximal stump was retrieved and resected with the safety margin, and anastomosis with leak test was performed. After a drain keeping, patient's position was changed back to supine again and laparoscopic irrigation and inspection of operation field was done finally. In the course of recovery, two patients were uneventful, but the rest with FAP experienced postoperative anastomotic leakage and got perineal resection and permanent ileostomy. According to our experience, posterior approach after laparoscopic TME permit right angle resection of distal rectum which is difficult in laparoscopic transabdominal approach. In addition, manual anastomosis with various instruments, Lembert suture, easy drain keeping, accurate fibrin glue apply can also be achieved. No incision on abdomen adds cosmetic advantage. But frequent position changes, need of patience-demanding intracorporeal mesenteric dissection to anastomotic site, and wound discomfort during sitting position right after the operation remain as challenges to consider and solve.

The Clinical Significance of Expression of Cyclooxygenase-2 in the Prognosis of the Papillary Thyroid Cancer / 대한내분비외과학회지

PURPOSE: It is well known that cyclooxygenase-2 (COX-2) is associated with carcinogenesis in many human cancers. In thyroid cancers, COX-2 expression in aging patients is known as a powerful prognostic factor of differentiated thyroid cancer. Therefore, in this study, we investigated the expression of COX-2 in cases of papillary thyroid cancer (PTC), as well as its association with other prognostic factors of thyroid cancer. METHODS: A total of 213 cases of papillary thyroid cancer were enrolled in this study and their clinicopathological characteristics were investigated retrospectively by a review of medicalrecords. Immunohistochemical staining for COX-2 was performed in the malignant tissue of the cases and the resultsof were then evaluated to determine if they were associated with other prognostic factors. RESULTS: The mean age of patients was 46 years (Range: 17~77 years old) and the tumor sizesranged from 0.1 to 5 cm (mean 1.2±0.9 cm). The pathological findings were as follows; thyroid capsule invasion in 101 patients (47%), lymph node metastasis in 76 patients (36%), multiplicity in 47 patients (22%), and bilaterality in 36 patients (17%). Positive results of immunohistochemical staining for COX-2 were noted in 131 patients (62%), however, the statistical analyses showed no significant association between COX-2 expression and other prognostic factors of papillary thyroid cancer. CONCLUSION: No association of COX-2 expression and prognostic factors of papillary thyroid cancer were found in this study. However, a larger prospectivestudy with survival analyses would provide a better understanding of thesignificance of COX-2 expression in cases of papillary thyroid cancer.

Spontaneous Rupture of the Spleen Secondary to Metastatic Choriocarcinoma

A spontaneous rupture of the spleen secondary to a metastatic choriocarcinoma is rare. To date, only five cases have been reported in the English literature. We report a case of a spontaneous rupture of the spleen secondary to a metastatic choriocarcinoma in a 29-year-old woman.

Association Studies of the Relationship Between Endometriosis and Polymorphism of the Detoxification Enzymes GSTT1, GSTM1, and CYP1A1 / 대한산부인과학회잡지

OBJECTIVE: Enzymes belonging to the Glutathione S transferase and cytochrome P450 families are involved in the two-stage detoxification process of a number of pro-carcinogens. We genotyped each 74 women with moderate or severe endometriosis and a control group of 93 women with a normal pelvis at cesarian section to investigate whether genetic polymorphism of CYP1A1, GSTT1, and GSTM1 are associated with endometriosis. MATERIALS AND METHODS: We investigate 74 women who were operated for endometriosis and 93 women who had no endometriotic lesion proved by operation. Polymerase chain reaction (PCR) and restriction fragment length polymorphism of PCR was done to determine each participant's genotype. RESULTS: We have found no significant differences between cases and controls in the frequencies of the GSTM1 and GSTT1 null mutations, or of the CYP1A1 MspI polymorphism does not differ significantly between groups. When GSTT1 and GSTM1 null mutation was combined with CYP1A1 MspI polymorphism, there was no significant differences between groups, either. CONCLUSION: Therefore, These low penetrance genes are not associated with increased susceptibility to endometriosis. Further studies are warranted to identify major susceptibility gene (s) and the mechanism involved in endometriosis to assist in the development of better methods for early detection, diagnosis and prevention.

Sonographic Evaluation of Breast Nodules: Comparison of Conventional, Real-Time Compound, and Pulse-Inversion Harmonic Images

OBJECTICE: To compare the use of conventional, real-time compound, and pulse-inversion harmonic imaging in the evaluation of breast nodules. MATERIALS AND METHODS: Fifty-two breast nodules were included in this study, conducted between May and December 2000, in which conventional, real-time compound, and pulse-inversion harmonic images were obtained in the same plane. Three radiologists, each blinded to the interpretations of the other two, evaluated the findings, characterizing the lesions and ranking the three techniques from grade 1, the worst, to grade 3, the best. Lesion conspicuity was assessed, and lesions were also characterized in terms of their margin, clarity of internal echotexture, and clarity of posterior echo pattern. The three techniques were compared using Friedman's test, and interobserver agreement in image interpretation was assessed by means of the intraclass correlation coefficient. RESULTS: With regard to lesion conspicuity, margin, and internal echotexture of the nodules, real-time compound imaging was the best technique (p < 0.05); in terms of posterior echo pattern, the best was pulse-inversion harmonic imaging (p < 0.05). Real-time compound and pulse inversion harmonic imaging were better than conventional sonography in all evaluative aspects. Interobserver agreement was greater than moderate. CONCLUSION: Real-time compound and pulse-inversion harmonic imaging procedures are superior to conventional sonography in terms of both lesion conspicuity and the further characterization of breast nodules. Real-time compound imaging is the best technique for evaluation of the margin and internal echotexture of nodules, while pulse-inversion harmonic imaging is very effective for the evaluation of the posterior echo patterns.

A relationship between polymorphism of estrogen receptor gene and bone mineral density in premenopausal Korean women / 대한산부인과학회잡지

OBJECTIVE: The goal of this study was to determine the relationship between peak bone density and polymorphism of estrogen receptor gene in Korean premenopausal women. METHOD: We amplified Estrogen receptor by polymerase chain reaction and its digestion pattern of Pvu II and Xba I was examined from the 172 women who were in premenopause. The genetic subtype was classified by its digestion pattern and its combination genotype, e.g. PP, Pp, pp, XX, Xx, xx, PPXX, PPXx, PPxx, PpXx, Ppxx, xxpp. Bone mineral density of each genetic subtype were compared. RESULTS: The genotype distribution was as follows: PP; 16.3%, Pp; 45.9%, pp; 37.8%, XX; 1.2%, Xx; 25.0%, xx; 73.8%, PPXX; 1.1%, PPXx; 8.7%, PPxx; 6.4%, PpXx; 16.3%, Ppxx; 29.7%, ppxx; 37.8%. ER gene polymorphism was associated with bone mineral density at forearm bone mineral density (P<0.05) with the xx genotype having the less BMD than Xx genotype. CONCLUSION: Xba I estrogen receptor gene polymorphism is associated with bone mineral density in premenopausal women. Estrogen receptor gene polymorphism may have a modulatory role in bone metabolism in premenopausal women. And it can be used as predictor of forearm peak bone density.

Spatio-Temporal Pattern Analysis in EEG of Alzheimer's Dementia: A Preliminary Report Using Karhunen-Loeve Method for Clinical Implication / 신경정신의학

OBJECTIVES: We introduce a novel analysis method of spatio-temporal pattern analysis of EEG. Using it, we presents a results discriminating severe Alzheimer's disease patients from normal subjects. METHOD: To the groups of 10 Alzheimer's disease patients and 10 normal aged subjects, we applied the Karhunen-Loeve decomposition method and observed their principal patterns and time-varying dynamics. RESULTS: First, there was a first primary pattern of the eigenvector in Alzheimer's disease patients that showed opposite polarities at the left and the right hemispheric regions. Second, the Alzheimer's disease patients had significantly different average values of the eigenvector at the left parieto-temporal area than the normal controls did. Third, some Alzheimer's disease patients had one, coherent frequency component in the Fourier amplitude spectrum of the first pattern expansion coefficient. CONCLUSION: Our results suggest that the pathophysiologic site of Alzheimer's dementia may be left temporo-parietal area in brain and further studies need to evaluate whether the spatio-temoral pattern analysis could be used to diagnose Alzheimer's dementia patients.

Radiologic and Histopathologic Evaluation of Various Contrast Media for Bronchography

PURPOSE: To determine which contrast media are both efficient and safe for the imaging of airways. MATERIALS AND METHODS: We evaluated five contrast media (barium, gastrografin, iotrolan, ioxaglate, iopentol) in terms of image quality and their effects on the lungs of 25 white rabbits. For bronchography 0.5ml of contrast media was used. In each contrast group, HRCT scans were obtained immediately (n=5), 12 hours (n=4), 1 day (n=3), 2 days (n=2), and 1 week (n=1) after bronchography. Histopathologic specimens were obtained immediately, 12 hours, 1 day, 2 days, and 1 week later. Bronchograms were evaluated for image quality by three radiologists working independently, and were scored as 1(poor), 2(moderate), or 3(good) in terms of contrast quality and bronchial coating. HRCT was evaluated by two radiologists who reached a concensus; they determined the presence of contrast media, and then the pattern and extent of pulmonary opacity, and any related changes. Histopatholgic specimens were evaluated by two pathologists who sought consensus as to the extent of inflammation, pulmonary edema, and hemorrhage, and any changes in these aspects. RESULTS: Bronchography indicated that the sum of scores for contrast quality was 45 for barium, 33 for gastrografin, 28 for iotrolan, 30 for ioxaglate, and 28 for iopentol, while for each of these media, the sum of scores for bronchial coating was 39, 19, 25, 23, and 21, respectively. Barium showed the best image quality. In all rabbits, HRCT demonstrated the variable extent of groundglass attenuation and/or consolidation. Lesions were most extensive at 1-2 days and then regressed at 1 week; these HRCT findings correlated well with histologic findings. In histologic studies of all five contrast media groups, variable severe inflammatory reactions were observed, with or without necrosis, congestion, edema, and hemorrhage. It was noted that ioxaglate appeared to cause least tissue reaction. CONCLUSIONS: The imaging results of this experimental study indicate that for bronchography, barium is the best available contrast media, On the basis of the histologic and HRCT results, however, ioxaglate is the best.

Mutation in p53 Tumor Suppressor Gene in Gestational Trophoblastic Neoplasia / 대한부인종양콜포스코피학회잡지

This study attempted to determine the status of tumor suppressor gene p53 in gestational trophoblstic neoplasia. In this study, 19 cases of hydatidiform moles and two choriocarcinoma cell lines(JAR, JEG-3) were evaluated for the presence of alterations of p53 gene. The p53 mutations were evaluated by nonisotopic olymerase chain reaction-single strand conformation polymorphism(PCR-SSCP) and automatic sequencing of PCR products in exons 5, 6, 7, 8. But we could not find any mutations of the p53 gene. This results suggest that p53 mutation maybe rarely involved in the pathogenesis of gestational trophoblastic neoplasia. And nonisotopic SSCP analysis by ethidium bromide staining is considered as an useful method for detecting single base differences in PCR products.