A Case of Septic Pulmonary Embolism Associated with MRSA Infective Endocarditis / 결핵및호흡기질환

Septic pulmonary embolism is the process in which an infected thrombus becomes detached from its site of origin and lodges in a pulmonary artery, and is usually associated with infective endocarditis, especially right-sided, or infection-associated with indwelling catheters, peripheral septic thrombophlebitis, and periodontal diseases, etc. Here, we report a case of septic pulmonary embolism associated with tricuspid valve infective endocarditis. A 23-year-old female was admitted to our hospital, due to fever, sore throat, and myalgia. In her past medical history, she had undergone a surgical operation for closure of a ventricular septal defect, but was informed that the operation resulted in an incomplete closure. The initial chest radiograph demonstrated multiple rounded, parenchymal nodules in various sizes; several nodules had central lucency suggesting cavitations. Echocardiography demonstrated a large vegetation attached to the septal tricuspid valve leaflet, extending from right ventricular inflow tract to outflow tract. Computed tomography of thorax revealed bilateral peripheral nodules and wedge-shaped consolidation at various sizes, mostly accompanied by cavitations.

A Case of Pulmonary Sparganosis in a Patient with a History of Recurrent Sparganum Infections / 결핵및호흡기질환

Sparganosis is a zoonosis caused by the migrating larvae of cestode genus Spirometra. We report a rare form of sparganosis that invades the lung. A 44-year-old man presented with newly appeared pulmonary nodules that were found accidentally on regular medical checkup, and on sequential chest CT, which we checked at an interval of every 2 months, revealed that the pulmonary lesion had migrated. The patient had a medical history of having undergone surgical excisions for sparganosis in muscles and in subcutaneous tissues of the lower abdomen, perianus, thigh, right axilla, and scapula area, several times over 7 years. A right middle lobectomy was performed and the lesion was diagnosed as sparganosis based on the characteristic histological findings.

A Case of Posttraumatic Pleural Effusion with Peripheral Eosinophilia / 결핵및호흡기질환

Eosinophilic pleural effusions (EPE) are defined as those effusions that contain at least 10% eosinophils, and EPE can be associated with peripheral blood eosinophilia in a variety of systemic diseases. There have been a few cases that have addressed the association of peripheral blood eosinophilia and posttraumatic EPE, and this condition can be misdiagnosed as being the result of other causes due to the delayed presentation. We report here on a case of 47-year-old male who presented with eosinophilic pleural effusion associated with peripheral blood eosinophilia at 2 months after minor chest trauma. We excluded the other possible causes such as consumption of drugs, parasite infection, malignancy, diseases of pulmonary eosinophilic infiltration, autoimmune diseases and pulmonary thromboembolism. We observed his clinical course without specific treatment. Three months later, the pleural effusion completely disappeared and the number of peripheral eosinophils returned to normal.

Clinical Findings of Critical Illness Polyneuropathy in Patients with Mechanical Ventilator Treatment / 대한구급학회지

BACKGROUND: Critical illness polyneuropathy (CIP) is a primary distal axonal degeneration of motor and sensory fibers leading to severe limb weakness and difficulty in weaning from ventilator in critically ill patients. The object of this study is to evaluate the clinical findings of CIP and the risk factors associated with CIP development in patients with mechanical ventilator treatment. METHODS: We examined 40 patients, between March 2002 to February 2003, who manifested muscular weakness and received mechanical ventilation (MV) more than three days, prospectively. Nerve conduction velocity (NCV) and electromyography (EMG) were performed in all patients in the ICU. We examined the use of drugs (neuromuscular blocking agents, corticosteroid, and aminoglycoside), duration of MV and weaning, and APACHE II score. RESULTS: We observed 40 patients who showed muscular weakness, 9 patients were diagnosed as CIP. NCV study demonstrated decreased action potential amplitude, predominantly in motor nerve, distal part. There was no significant difference in duration of MV and weaning, drug use, APACHE II score between the groups with CIP and without CIP. CONCLUSIONS: CIP is an important neuromuscular complication of the patients in ICU. We should consider the possibility of the development of CIP in patients who showed muscular weakness and difficult weaning in critically ill patients.

A Case of Drug Induced Interstitial Pneumonitis by Gemcitabine / 결핵

Gemcitabine is an effective newly developed chemotherapeutic agent, which is increasingly being used to treat non-small cell lung, ovarian and breast cancers. Pulmonary toxicity is usually self-limiting mild dyspnea, bronchospasm, but severe pulmonary toxicity is rarely reported. Herein, we report drug induced interstitial lung disease associated with gemcitabine treatment. High resolution computerized tomogram (HRCT) showed an increased ground glass opacity and thickened septal lines. The patient showed a rapid good response with prednisolone treatment.

Treatment of Bilateral Diaphragmatic Paralysis after Resection of Thymic Carcinoma: One case report / 대한흉부외과학회지

Bilateral diaphragmatic paralysis is a rare disease. It is caused by trauma, cardiothoracic surgery, neuromuscular disorders, cervical spondylosis, and infection. A 60 year-old male patient developed bilateral diaphragmatic paralysis after an en-bloc resection of thymic carcinoma which invaded the right upper lobe, pericardium, superior vena cava and innominate vein. Severe respiratory difficulty developed and ventilator weaning was impossible. We performed bilateral diaphragmatic plication. After the operation, satisfactorily ventilator weaning and sleeping in supine position were possible; therefore, we report this case.

A Case of Endobronchial Actinomycosis

Actinomycosis is an infectious disease caused by certain Actinomyces species. Actinomyces are Gram-positive, non-spore forming organisms characterized by obligate or facultative anaerobic rods that normally inhabit anaerobic niches of the human oral cavity. Cervicofacial, abdominal, pelvic and thoracic infections of Actinomyces are not uncommon, but endobronchial actinomycosis is rarely reported. Endobronchial actinomycosis can be misdiagnosed as unresolving pneumonia, endobronchial lipoma or malignancies. Endobronchial actinomycosis should be included in the differential diagnosis of any endobronchial mass. We report a case of a 43-year-old man who presented with a productive cough and pulmonary consolidation at the right lower lobe on chest radiograph. Fiberoptic bronchoscopy revealed obstruction of the right superior segment of the lower bronchus with an exophytic endobronchial mass. Endobronchial actinomycosis was confirmed by demonstration of sulfur granules in the bronchoscopic biopsy of the mass. Intravenous administration of penicillin G followed by oral amoxacillin/clavulanic acid therapy for 3 months resulted in improving symptoms. Infiltrative consolidation on the chest X-ray was markedly decreased.

Role of nitric oxide and molsidomine in the management of pulmonary hypertension in Takayasu's arteritis / 결핵

We report three patients with pulmonary hypertension in Takayasu's arteritis, who showed long-term favorable response, clinically and hemodynamically, to the nitric oxide donor, molsidomine. In these patients, the inhaled nitric oxide was effective in reducing pulmonary artery pressure (PAP) and pulmonary vascular resistance (PVR) as was shown in the acute vasodilator response test using the invasive hemodynamic monitoring. Molsidomine (single oral dose of 4 mg) was also effective in reducing PAP and PVR in the acute test, but nifedipine was not. With 4 mg of molsidomine three times daily, their dyspnea, exercise capacity and hemodynamic parameters were improved. These favorable responses have lasted during the 1st and 3rd month follow-up in all patients.

Study for diagnostic efficacy of minibronchoalveolar lavage in the detection of etiologic agents of ventilator-associated pneumonia in patients receiving antibiotics / 결핵

BACKGROUND: Early diagnosis and proper antibiotic treatment are very important in the management of ventilator-associated pneumonia (VAP) because of its high mortality. Bronchoscopy with a protected specimen brush (PSB) has been considered the standard method to isolate the causative organisms of VAP. However, this method burdens consumer economically to purchase a PSB. Another useful method for the diagnosis of VAP is quantitative cultures of aspirated specimens through bronchoscopic bronchoalveolar lavage (BAL), for which the infusion of more than 120 ml of saline has been recommended for adequate sampling of a pulmonary segment. But occasionally it leads to deterioration of the patient's condition. We studied the diagnostic efficacy of minibronchoalveolar lavage (miniBAL), which retrieves only 25 ml of BAL fluid, in the isolation of causative organisms of VAP. METHODS: We included 38 consecutive patients (41 cases) suspected of having VAP on the basis of clinical evidence, who had received antibiotics before the bronchoscopy. The two diagnostic techniques of PSB and miniBAL, which were performed one after another at the same pulmonary segment, were compared prospectively. The cut-off values for quantitative cultures to define causative bacteria of VAP were more than 10(3) colony-forming units (cfu)/ml for PSB and more than 10(4) cfu/ml for BAL. RESULTS: The amount of instilled normal saline required to retrieve 25 ml of BAL fluid was 93 +/- 32 ml (mean +/- SD). The detection rate of causative agents was 46.3% (19/41) with PSB and 43.9% (18/41) with miniBAL. The concordance rate of PSB and miniBAL in the bacterial culture was 85.4% (35/41). Although arterial blood oxygen saturation dropped significantly (p<0.05) during (92 +/- 10 %) and 10 min after (95 +/- 3 %) miniBAL compared with the baseline (97 +/- 3 %), all except 3 cases were within normal ranges. The significantly elevated heart rate during (125 +/- 24/min, p<0.05) miniBAL compared with the baseline (111 +/- 22/min) recovered again in 10 min after (111 +/- 26/min) miniBAL. Transient hypotension was developed during the procedure in two cases. The procedure was stopped in one case due to atrial flutter. CONCLUSION: MiniBAL is a safe and effective technique to detect the causative organisms of VAP.

The Respiratory and Hemodynamic Effects of Prone Position According to the Level of PEEP in a Dog Acute Lung Injury Model / 결핵

BACKGROUND: Prone position improves oxygenation in patients with ARDS probably by reducing shunt Reduction of shunt in prone position is thought to be effected by lowering of the critical opening pressure (COP) of the dorsal lung because the pleural pressure becomes less positive in prone position compared to supine position. It can then be assumed that prone position would bring about greater improvement in oxygenation when PEEP applied in supine position is just beneath COP than when PEEP is above COP. Hemodynamically, prone position is expected to attenuate the lifting of cardiac fossa induced by PEEP. Based on these backgrounds, we investigated whether the effect of prone position on oxygenation differs in magnitude according to the level of PEEP applied in supine position, and whether impaired cardiac output in supine position by PEEP can be restored in prone position. METHOD: In seven mongrel dogs, PaO2/FIO2(P/F) was measured in supine position and at prone position 30min. Cardiac output (CO), stroke volume (SV), pulse rate (PR), and pulmonary artery occlusion pressure (PAOP) were measured in supine position, at prone position 5 mm, and at prone position 30 mm. After ARDS was established with warmed saline lavage(P/F ratio 134+/-72 mmHg), inflection point was measured by constant flow method(6.6+/-1.4 cm H2O), and the above variables were measured in supine and prone positions under the application of Low PEEP(5.0+/-1.2 cm H2O), and Optimal PEEP(9.0+/-1.2 cm H2O) (2cm H2O below and above the inflection point, respectively) consecutively. RESULTS: P/F ratio in supine position was 195+/-112 mmHg at Low PEEP and 466+/-63 mmHg at Optimal PEEP(p=0.003). Net increase of P/F ratio at prone position 30 mm, however, was far greater at Low PEEP (205+/-90 mmHg) than at Optimal PEEP(33+/-33 mmHg) (p=0.009). Compared to CO in supine position at Optimal PEEP(2.4+/-0.5 L/min), CO in prone improved to 3.4+/-0.6 L/min at prone position 5 mm (p=0.0180) and 3.6+/-0.7 L/min at prone position 30 mm (p=0.0180). Improvement in CO was attributable to the increase in SV : 14+/-2ml in supine position, 20+/-2ml at prone position 5 mm (p=0.0l80), and 21+/-2ml at prone position 30 mm (p= 0.0180), but not to change in PR or PAOP. When the dogs were turned to supine position again, MAP (92+/-23 mmHg, p=0.009), CO (2.4+/-0.5 L/min, p=0.0277) and SV (14+/-1ml, p=0.0277) were all decreased compared to prone position 30 min. CONCLUSION: Prone position in a dog with saline-lavaged acute lung injury appeared to augment the effect of relatively low PEEP on oxygenation, and also attenuate the adverse hemodynamic effect of relatively high PEEP. These findings suggest that a PEEP lower than Optimal PEEP can be adopted in prone position to achieve the goal of alveolar recruitment in ARDS avoiding the hemodynamic complications of a higher PEEP at the same time.

Detection of Pyrazinamide-Resistant Mycobacteriumtuberculosis by PCR-SSCP of pncA Gene / 결핵

BACKGROUND: Recently the incidence of tuberculosis is increasing in many countries and control of the disease is further threatened by the emergence of multi-drug resistant tuberculosis. So rapid detection of drug resistance is very important. Pyrazinamide (PZA) is a first-line chemotherapeutic agent for tuberculosis. Now in Korea, we perform PAase activity test instead of actual pyrazinamide susceptibility test for the detection of PZA resistant M. Tuberculosis. Recently the pncA gene, encoding the PZase of M. Tuberculosis, was completely sequenced. And it was reported that the mutation of pncA gene would be associated with PZA resistance of M. Tuberculosis. Therefore we performed this study to evaluate the possibility for the rapid detection of PZA resistant M. Tuberculosis using RCR-SSCR of pncA gene. METHOD: 44 cultured clinical isolates of M. tuberculosis, BCG Tokyo strain, BCG french strain, and one M.bovis isolate were studied. We used H37Rv as the reference strain, The PZase activity test was done at the reference laboratory of Korean Tuberculosis Institute. DNA was extracted by bead-beater method and 561 bp fragment including pncA gene was amplified by PCR. The PCR product were digested by BstB I enzyme. SSCP was done using MDE gel. Of the 44 strains of M. tuberculosis, 22 strains were PZase-positive and other 22 strains were PZase negative. RESULTS: Of the 22 PZase positive strains, 18 strains(82%) showed the same mobility compared with that of H37Rv and 4(18%) showed different mobility. Of the PZase negative strains, 19(86%) strains showed the same mobility pattern compared with that H37Rv and 3(14%) showed different mobility. Naturally PZA-resistant BCG-French strain, BCG-Tokyo strain, and one M. bovis isolate showed the same band pattern each other, but their mobility were different from that of H37Rv. The results of PZase activity test and PCR-SSCP of pncA of M tuberculosis were statistically significantly correlated each other(p<0.01). CONCLUSION: The PCR-SSCP after BstB I restriction of pncA gene of M tuberculosis may be a useful method for the rapid detection of PZA-resistant M. tuberculosis.

The Combined Therapy of Inhaled Nitric Oxide and Prone Positioning Has an Additive Effect on Gas Exchange and Oxygen Transport in Patients with Acute Respiratory Distress Syndrome / 결핵

BACKGROUND AND OBJECTIVE: Although prone positioning has been reported to improve gas exchange, prone positioning alone does not seem to be sufficient to increase systemic oxygen transport in an acute lung injury. The objective of this study was to investigate whether the combined therapy of low dose nitric oxide (NO) inhalation and prone positioning has an additive effect on the oxygenation and hemodynamics in patients with severe ARDS. PATIENTS AND METHODS: Twelve patients with ARDS were included. Prone positioning alone, later combined with nitric oxide inhalation (5~10 ppm) from the supine position (baseline) were performed with serial measurement of gas exchange, respiratory mechanics and hemodynamic at sequential time points. The patient was regarded as a responder to prone positioning if an increase in PaO2/FiO2 of more than 20 mmHg at 30 min or 120 min intervals after prone positioning was observed compared to that of the baseline. The same criterion was applied during nitric oxide inhalation. RESULTS: Eight patients (66.5%) responded to prone positioning and ten patients (83.3%) including the eight just mentioned responded to the addition of NO inhalation. The AaDO2 level also decreased promptly with the combination of prone positioning and NO inhalation compared to that of prone positioning alone (191+/-109 mmHg. 256137 mmHg, P<0.05). Hemodynamic parameters and lung compliance did not change significantly during prone positioning only. Following the addition of NO inhalation to prone positioning, the mean pulmonary artery pressure and pulmonary artery occlusion pressure decreased and cardiac output, stroke volume and oxygen delivery increased (P0.05) compared to those of prone 120 min. CONCLUSION: These findings indicate that NO inhalation would provide additional improvement in oxygenation and oxygen transport to mechanically ventilated patients with ARDS who are in a prone position.

Comparison of Clinical Efficacy Between Percutaneous Dilatational Tracheostomy and Surgical Tracheostomy / 결핵

BACKGROUND: Surgical tracheostomy(ST) is usually performed by surgeons in operating room. For a patient with mechanical ventilation, however, transportation to operating room for ST could be dangerous for patients. In addition, ST is often delayed due to unavailability of operating room or surgeon. Percutaneous dilatational tracheostomy (PDT), although novel in Korea, is gaining popularity as a bedside procedure in the hospitals of western countries. We evaluated the technical ease and safety of PDT in comparison with ST. METHOD: Thirty-eight patients in medical intensive care unit (ICU) who were either under mechanical ventilation for more than 7 days or required airway protection, were randomly assigned to ST(18 patients) or PDT(20 patients). Between two groups, there was no significant clinical difference except that female to male ratio was higher in the ST group. ST was performed by second year residents of the department of otolaryngology while PDT was performed by third grade medical resident and pulmonologist under bronchoscopic guide using Ciaglia Percutaneous Tracheostomy Set (Cook Critical Care, Bloomington, USA) in medical ICU. The following factors were compared between two groups : number of delayed cases after the decision for tracheostomy, procedural time, complications related to tracheostomy. RESULTS: Delayed cases were 11 in ST group and 3 in PDT group (P0.05). CONCLUSION: Since percutaneous dilatational tracheostomy was easy to practice and its complications wert not different from surgical tracheostomy, PDT can be a useful bedside procedure for mechanically ventilated patients.

The Effect of External PEEP on Work of Breathing in Patients with Auto-PEEP / 결핵

BACKGROUND: Auto-PEEP which develops when expiratory lung emptying is not finished until the beginning of next inspiration is frequently found in patients on mechanical ventilation. Its presence imposes increased risk of barotrauma and hypotension, as well as increased work of breathing (WOB) by adding inspiratory threshold load and/or adversely affecting to inspiratory trigger sensitivity. The aim of this study is to evaluate the relationship of auto-PEEP with WOB and to evaluate the effect of PEEP applied by ventilator (external PEEP) on WOB in patients with auto-PEEP. METHOD: 15 patients, who required mechanical ventilation for management of acute respiratory failure, were studied. First, the differences in WOB and other indices of respiratory mechanics were examined between 7 patients with auto-PEEP and 8 patients without auto-PEEP. Then, we applied the 3 cm H2O of external PEEP to patients with auto-PEEP and evaluated its effects on lung mechanics as well as WOB. Indices of respiratory mechanics including tidal volume (V(T)), repiratory rate, minute ventilation (V(E)), peak inspiratory flow rate (PIFR), peak expiratory flow rate (PEFR), peak inspiratory pressure (PIP), T(I)/T(TOT), auto-PEEP, dynamic compliance of lung (Cdyn), expiratory airway resistance (RAWe), mean airway resistance (RAWm), P(0.1), work of breathing performed by patient (WOB), and pressure-time product (PTP) were obtained by CP-100 Pulmonary Monitor (Bicore,USA). The values were expressed as meanSEM (standard error of mean). RESULTS: 1) Comparison of WOB and other indices of respiratory mechanics in patients with and without auto-PEEP: There was significant increase in WOB (1.71 +/-0.24 vs 0.500.19 J/L, p=0.007), PTP (317+/-70 vs 98+/-36 cm H2O * sec/min, p=0.023), RAWe (35.6+/-5.7 vs 18.2+/-2.3 cm H20/L/sec, p=0.023), RAWm (28.8+/-2.5 vs 11.9+/-2.0 cm H2O/L/sec, p=0.001) and P0.1 (6.21.0 vs 2.9+0.6 cm H2O, p=0.021) in patients with auto-PEEP compared to patients without auto-PEEP. The differences of other indices including V(T), PEFR, V(E) and T(I)/T(TOT) showed no significance. 2) Effect of 3 cm H2O external PEEP on respiratory mechanics in patients with auto-PEEP: When 3 cm H2O of external PEEP was applied, there were significant decrease in WOB (1.71+/-0.24 vs 1.20+/-0.21 J/L, p=0.021) and PTP (317+/-70 vs 231+/-55 cm H2O * sec/min, p=0.038). RAWm showed a tendency to decrease (28.8+/-2.5 vs 23.9+/-2.1 cm H2O, p=0.051). But PIP was increased with application of 3 cm H2O of external PEEP (16+/-2 vs 22+/-3 cm H2O, p=0.008). V(T), V(E), PEFR, T(I)/T(TOT) and Cdyn did not change significantly. CONCLUSION: The presence of auto-PEEP in mechanically ventilated patients was accompanied with increased WOB performed by patient, and this WOB was decreased by 3 cm H2O of externally applied PEEP. But, with 3 cm H2O of external PEEP, increased PIP was noted, implying the importance of close monitoring of the airway pressure during application of external PEEP.

A case of insulinoma localized by endoscopic ultrasonography / 대한내분비학회지

No abstract available.

A clinical study of hepatocellular carcinoma with major bile duct invasion / 대한내과학회지

No abstract available.

A Case of Choledochocele / 대한소화기내시경학회지

A choledochocele is a benign cyst-like herniation of the intramural segment of the distal common bile duct protruding into the duodenal lumen. Cholangiography is essential to demonstrate a choledochocele. Because choledochoceles are often associated with characteristic structual alterations of the papilla of Vater and the peripapillary area, ERCP is helpful in demonstrating a choledochocele. We present the clinical, endoscopic and radiographic (ERCP) findings in a patient with choledochocele.

A Case of Choledochocele / 대한소화기내시경학회지

A choledochocele is a benign cyst-like herniation of the intramural segment of the distal common bile duct protruding into the duodenal lumen. Cholangiography is essential to demonstrate a choledochocele. Because choledochoceles are often associated with characteristic structual alterations of the papilla of Vater and the peripapillary area, ERCP is helpful in demonstrating a choledochocele. We present the clinical, endoscopic and radiographic (ERCP) findings in a patient with choledochocele.