A Case of Hyperglycemic Hyperosmolar State Associated with Graves' Hyperthyroidism: A Case Report

Hyperglycemic hyperosmolar state (HHS) is an acute complication mostly occurring in elderly type 2 diabetes mellitus (DM). Thyrotoxicosis causes dramatic increase of glycogen degradation and/or gluconeogenesis and enhances breakdown of triglyc-erides. Thus, in general, it augments glucose intolerance in diabetic patients. A 23-yr-old female patient with Graves' disease and type 2 DM, complying with methimazole and insulin injection, had symptoms of nausea, polyuria and generalized weakness. Her serum glucose and osmolarity were 32.7 mM/L, and 321 mosm/kg, respectively. Thyroid function tests revealed that she had more aggravated hyperthyroid status; 0.01 mU/L TSH and 2.78 pM/L free T3 (reference range, 0.17-4.05, 0.31-0.62, respectively) than when she was discharged two weeks before (0.12 mU/L TSH and 1.41 pM/L free T3). Being diagnosed as HHS and refractory Graves' hyperthyroidism, she was treated successfully with intravenous fluids, insulin and high doses of methimazole (90 mg daily). Here, we described the case of a woman with Graves' disease and type 2 DM developing to HHS.

Acquired Pure Red Cell Aplasia due to Anti-Erythropoietin Antibodies in a Patient Undergoing Hemodialysis

A 63-year-old man was placed on hemodialysis for the end-stage of renal disease secondary to renal artery stenosis. He was also regularly given epoetin, subcutaneously, for anemia associated with his renal disease. Rapidly progressing erythropoietin (EPO) resistant anemia and reticulocytopenia developed after 1 year of hemodialysis. The patient required frequent red blood cell transfusions. The bone marrow examination demonstrated selective erythroid hypoplasia. A detailed search for the cause of the erythroblastopenia revealed nothing, with the exception of anti-EPO antibodies (Ab). Pure red cell aplasia (PRCA) was suspected due to the anti-EPO Ab. With the immunosuppressive agent and change to the epoetin-therapy, the patient recovered his hemoglobin and reticulocyte counts. Particular attention should be paid for the possibility of PRCA due to anti-EPO Ab in patients undergoing rHuEPO therapy, with an unexplained recombinant human erythropoietin (rHuEPO) resistant anemia, especially via the subcutaneous route.

A Case of Hypothyroidism and Type 2 Diabetes Associated with Type V Hyperlipoproteinemia and Eruptive Xanthomas

Primary hypothyroidism and type 2 diabetes are both typically associated with the increased level of triglycerides. To date, there have been only a few case reports of type 2 diabetes patients with both type V hyperlipoproteinemia and eruptive xanthomas, but there have been no reports of hypothyroidism patients associated with eruptive xanthomas. We report here on a case of a 48-yr old female patient who was diagnosed with type 2 diabetes and primary hypothyroidism associated with both type V hyperlipoproteinemia and eruptive xanthomas. We found rouleaux formation of RBCs in peripheral blood smear, elevated TSH, and low free T4 level, and dyslipidemia (total cholesterol 18.1 mM/L, triglyceride 61.64 mM/L, HDL 3.0 mM/L, and LDL 2.54 mM/L). She has taken fenofibrate, levothyroxine, and oral hypoglycemic agent for 4 months. After treatment, both TSH level and lipid concentration returned to normal range, and her yellowish skin nodules have also disappeared.

Relationship between Change of RBC Shape and Multi-organ Failure in Sepsis / 대한구급학회지

BACKGROUND: Microcirculatory derangement in sepsis plays a crucial role in the impairment of tissue oxygenation that can lead to multi-organ failure and death. The change of RBC rheology in sepsis has been known to be important factors in microcirculatory derangement. Several studies have demonstrated that RBCs have decreased deformability in sepsis. We investigated the relationship between multi-organ failure and spherical index of RBC estimated by flow cytometer in critically ill patients with or without sepsis compared with the relationship in healthy volunteers. METHODS: Fourteen non-septic critically ill patients, 18 septic patients and 10 healthy volunteers were evaluated. We obtained peripheral venous blood from each patient and analyzed the change of RBC shape using flow cytometer (Becton Dickinson FACSCalibur) within 90 minute. The change of RBC shape was accessed with spherical index (M2/M1). A decrease in M2/M1 was correlated with the sphericity of the RBC and considered to have a lower capacity to alter their shape when placed in microcirculation. Multi-organ failure was accessed with sequential organ failure assessment (SOFA) score. RESULTS: The M2/M1 ratio of healthy volunteers, non-septic patients and septic patients were 2.25+/-0.08, 2.16+/-0.39 and 2.05+/-0.53, respectively. But, there was no significant difference between each group (p>0.05). And, there was no significant correlation between M2/M1 ratio of septic and non- septic patients and SOFA score (p>0.05, r2= -0.13). CONCLUSIONS: In our study, the spherical index of RBC was not associated with multi-organ failure in sepsis. But, further studies may be needed to evaluate the role of RBC rheology in sepsis.

A Case of Trichosporon beigelii Peritonitis in CAPD / 대한신장학회잡지

Fungal peritonitis is one of the leading causes of patient dropout from continuous ambulatory peritoneal dialysis (CAPD) therapy. Although the most causative agents of peritonitis associated with CAPD are bacteria, fungi are implicated in up to 10% of cases. The most common organism of fungal peritonitis is Candida specises, but Trichosporon beigelii was reported as a rare causative agent of fungal peritonitis. We experienced a case of CAPD peritonitis by Trichosporon beigelii, which was treated with CAPD catheter removal, and antifungal agents with amphotericin B and fluconazole. Thus, we report our experience of CAPD peritonitis caused by Trichosporon beigelii and review of the literature.

Experience of HLA Antibody Testing in the International Serum Exchange Program / 대한진단검사의학회지

BACKGROUND: When organ transplantation or HLA-matched platelet transfusion is considered, accu-rate identification of HLA antibody specificity in the recipient's serum is very important. In this study, we report our experience in an international quality control program. METHODS: For external quality control in a HLA antibody test, the International Serum Exchange Program distributes serum samples, generally showing polyspecific reactivity for cross-reactive epitope groups (CREGs), to participating laboratories: 4 samples per survey, 10 surveys per year. Participating in the program from May 1998 to August 2000 (24 surveys), we performed HLA antibody identification of 96 serum samples by the AHG-CDC (anti-human globulin-complement dependent cytotoxicity) method using frozen lymphocyte trays (36 lymphocyte panels). We compared the results of our laboratory with those of the total participants (all methods combined, 72 to 92 laboratories per survey) using the analyzed survey results distributed by the program organizer. RESULTS: We analyzed the survey results for the antibodies to relatively common HLA antigens in Koreans (antigen frequency >1%). For the HLA antibodies detected in >or=20% of participants, our detection rate was higher by 10-15% than that of all laboratories (HLA-A, 76% vs 65%; HLA-B, 73% vs 57%). And for the HLA antibodies detected in >or=50% of the participants, our detection rate was as high as 88% for HLA-A and 87% for HLA-B. Our detection rate for a few antibody specificities was lower than that of all laboratories, namely HLA-A1, A3, B35, and B55. Among these, A1, A3, and B55 were of lower incidence antigens in Koreans (antigen frequency 3-4%), indicating that the low detection rate was due to a limitation in the composition of lymphocyte panels. CONCLUSIONS: In general, our detection rate of HLA antibodies was superior to the average detection rate of the total participant laboratories. We would be able to improve the low detection rate for a few antibody specificities to lower incidence antigens by refining the composition of lymphocyte panels.

Comparison of serotypes, restriction enzyme analysis of plasmid DNA pattern and PFGE(pulsed-field gel electrophoresis) patterns of Yersinia pseudotuberculosis isolates in Korea / 대한임상병리학회지

BACKGROUND: Yersinia pseudotuberculosis, a member of genus Enterobactericeae, is a main etiologic organism of diarrhea in childhood. Because a mouse and a unchlorinated spring water are main reservoirs of Y. pseudotuberculosis, the strains from a contaminated spring water and mouse could be involved in human epidemic. The purpose of this study was to investigate a clonality between the strains from patients and those from an unchlorinated spring water and a mouse by restriction enzyme analysis of plasmid DNA and pulsed-field gel electrophoresis (PFGE). METHOD: We isolated 15 Y. pseudotuberculosis strains including 8 isolates from patients (S1-S8), 6 isolates from mountain water (W1-W6), 1 isolate from a mouse (M1) in northeast area of Seoul. Plasmid and chromosomal DNA of all strains were analyzed by REAP with Bam H1 restriction and by PFGE with Xba I restriction , respectively. RESULTS: Restriction enzyme analysis of plasmid DNA was classified into type B and type D. All 7 strains of serotype 15 were classified as type B and 8 strains of serotype 4b were classified as type D. PFGE were classified into 6 different types. Among them, strains of PFGE type I, II, III, IV belong to Y. pseudotuberculosis serotype 15 and Y. pseudotuberculosis 4b strains were classified into PFGE type V, VI. S1 and W1 were classified into PFGE type I . S8, W6 and M1 were classfied into PFGE type VI. CONCLUSIONS: PFGE revealed clonality among strains from patients, a water and a mouse. PFGE was more discriminative than REAP to characterize the Y. pseudotuberculosis outbreaks in Korea.

Epidemiological Studies of Yersinia pseudotuberculosis Infection by Plasmid DNA Profile Assay / 감염

BACKGROUND: In order to investigate transmission route of Yersinia pseudotuberculosis infection in Korea, we tried epidemiological study among human strains, mountain spring water strain and wild mouse strain which were isolated in north eastern area of Seoul on spring in 1996. METHODS: Plasmid profile (Restriction Endonuclease Analysis of Virulence Plasmid DNA analysis: REAP) assay in addition to serotyping were performed among human strains, mountain spring water strain and wild mouse strains. RESULTS: All isolates were the same O serotype of 4b and the same REAP pattern of type D. CONCLUSION: These results suggested that wild mice (especially Apodemus agrarius) were one of main reservoir of Y. pseudotuberculosis in Korea and their fecal material might contaminate mountain spring water. Most of human infections of Y. pseudotuberculosis were originated from drinking of contaminated mountain spring waters in Korea.

Epidemiological Investigation of Yersinia pseudotuberculosis Infection in Korean / 대한임상병리학회지

BACKGROUND: The purpose of this study is to prove that human infection of Yersinia pseudotuberculosis might be occurred by drinking of mountain spring water contaminated with wild mice excreta through epidemiological tool. METHOD: Y. pseudotuberculosis strains which were isolated from patient stools, mountain spring water and mice excreta were analysed by serotyping of O antigen and plasmid DNA profile (Restriction Endonuclease Analysis of Plasmic DNA analysis REAP) assay Also reservoir rate of Y. pseudotuberculosis was calculated from wild mice which were captured throughout Korean mountains. RESULTS: Reservoir rate of Y. pseudotuberculosis from wild mice in Korea was 0.85% and was not higher than that in other country. The analysis of 66 strains of Y. pseudotuberculosis showed that 36 strains of serotype 15, REAP B type, 24 strains of serotype 4b, REAP D type, and 1 strain of serotype 4b, REAP new unclassifiable type, but 5 strains didn't have plasmic (serotype 15:3, 11 :2) .Especially same 4b, D type of Y. pseudotuberculosis was isolated from patient stools, mountain spring water and wild mouse (Apodemus agrarius) excretion and this fact was considered that Y. pseudotuberculosis strains from 3 groups were closely correlated epidemiologically. Also serotype 15, REAP B strains were isolated from patient stools and mountain spring water, but were not isolated from wild mice yet and 15, B type was isolated from Korea only and considered as native Korean strain which had not isolated in other countries yet. CONCLUSIONS: Human Y. pseudotuberculosis infection in Korea was occurred by drinking of contaminated mountain spring water and A. agrarius was one of main reservoir which contaminates mountain spring waters in Korea, Also above antigenic distribution of Y. pseudotuberculosis would be useful for development of ELISA kit of Korean type.