Blue toe syndrome treated with sympathectomy in a patient with acute renal failure caused by cholesterol embolization

Blue toe syndrome is the most frequent manifestation of tissue ischemia caused by cholesterol embolization (CE), which can lead to amputation of affected lower extremities, if severe. However, any effective treatment is lacking. We experienced a case of spontaneously presenting blue toe syndrome and concomitant acute renal failure in a patient with multiple atherosclerotic risk factors. CE was confirmed by renal biopsy. Despite medical treatment including prostaglandin therapy and narcotics, the toe lesion progressed to gangrene with worsening ischemic pain. Therefore, we performed lumbar sympathectomy, which provided dramatic pain relief as well as an adequate blood flow to the ischemic lower extremities, resulting in healing of the gangrenous lesion and avoiding toe amputation. This is the first reported case of a patient with intractable ischemic toe syndrome caused by CE that was treated successfully by sympathectomy. Our observations suggest that sympathectomy may be beneficial in some patients with CE-associated blue toe syndrome.

Austrian Syndrome with a Delayed Onset of Heart Failure

A 59-year-old man treated with pneumococcal meningitis 4 months ago was hospitalized for acute heart failure and performed aortic valve replacement by rupture of aortic valve. The frequent association of pneumococcal meningitis and endocarditis is known as Austrian syndrome. Though Austrian syndrome is a clinically rare disease, the evolution of pneumococcal endocarditis is very aggressive and associated with high mortality, and early recognition for evidence of endocardial lesion in patients with pneumococcal meningitis is important to reduce the complications and mortality rate.

Comparison of the BACTEC Blood Culture and Conventional Culture Methods for Isolation of Microorganisms Causing Peritonitis in CAPD Patients / 대한내과학회지

BACKGROUND/AIMS: Peritonitis is the most frequent complication of continuous ambulatory peritoneal dialysis (CAPD). Prompt recognition and treatment of peritonitis is important. The purpose of this study was to compare the effectiveness of isolation of the microorganisms causing CAPD peritonitis by the BACTEC blood culture and conventional methods. METHODS: We retrospectively reviewed 38 episodes of peritonitis in 34 CAPD patients between September 2007 and February 2010. Two methods of processing dialysate from patients on CAPD were used. Blood culture was performed using two 10-mL effluents, which were inoculated into a pair of BACTEC culture bottles. The conventional method was performed using 50 mL of centrifuged dialysate. The sedimented dialysate was inoculated onto blood agar and MacConkey agar plates or into thioglycollate broth. To evaluate effectiveness, we compared the rate of positive culture results and the time to identify the causative organism of the two culture methods. RESULTS: Use of the BACTEC bottle method resulted in more positive culture results than did conventional culture (86.8 vs. 57.9% p = 0.003). The time taken to identify the causative organism from culture-positive peritonitis was more rapid using the blood culture compared with the conventional culture method (90 vs. 109 hr, p = 0.03). CONCLUSIONS: Blood culture using the BACTEC bottle is more effective than the conventional culture technique for detection of causative microorganisms in CAPD peritonitis.

Spontaneous Pneumomediastinum, Pneumothorax, and Subcutaneous Emphysema Complicating H1N1 Virus Infection / 대한내과학회지

Since April 2009, outbreaks of the new influenza A (H1N1) virus have occurred worldwide. The spectrum of disease caused by H1N1 infection ranges from non-febrile, mild upper respiratory tract illness to severe or fatal pneumonia. Rapidly progressive respiratory diseases, such as acute respiratory distress syndrome and renal or multi-organ failure, have accounted for severely affected inpatients. Complex cases involving myocarditis, encephalitis, and myositis have been described. However, pulmonary air-leak syndrome, consisting of spontaneous pneumomediastinal emphysema, pneumothorax, and subcutaneous emphysema complicating pneumonia with the H1N1 virus, has not previously been reported in Korea. Here, we report a case of pulmonary air-leak syndrome complicating H1N1 infection that was resolved with an antiviral agent, high-flow oxygen, and fluid therapy.

Analysis of adverse drug reactions collected by an electronic reporting system in a single hospital / 대한내과학회지

BACKGROUND/AIMS: The recent introduction of computerized surveillance systems has promoted the monitoring of adverse drug reactions (ADRs), a feature that facilitates voluntary reports and enables prompt feedback. To investigate the causative agents and severity of ADRs that occurred in a single hospital, we analyzed the features of 980 ADRs that occurred over 14 months after developing a computerized ADR reporting system in Hallym Sacred Heart Hospital. METHODS: ADR data collected prospectively from September 2007 to October 2008 by a computerized reporting system were analyzed. The World Health Organization-Uppsala Monitoring Center (WHO-UMC) criteria were used to determinate causality for each ADR. RESULTS: The number of ADR cases reported voluntarily increased rapidly since the introduction of the computerized ADR reporting system. Of the 980 cases, antibiotics (34.5%) were the most common causative drugs, followed by analgesics such as tramadol and its compound (15.2%), radiocontrast media (7.0%), narcotics (5.9%), and nonsteroidal anti-inflammatory drugs (NSAIDs) (5.5%). Fifty-nine (6.0%) and 206 (21.0%) cases were classified as severe and moderate reactions, respectively. The mean age was older in patients with severe ADRs than in patients with non-severe ADRs. The most common clinical features were skin manifestations, such as pruritus, skin eruptions, and urticaria. Gastrointestinal symptoms including nausea, vomiting, and diarrhea were the second most frequently reported ADRs. Among antibiotics, first-generation cephalosporins were the most frequently reported causative drugs, followed by second-generation cephalosporins, penicillin/beta-lactamase inhibitors, and third-generation cephalosporins. While 11.6% of ADRs related to penicillin/beta-lactamase inhibitors were classified as severe, there was only one severe ADR (1.1%) for first-generation cephalosporins. Most ADRs were reported equally in men and women, although female cases constituted about two thirds of ADRs associated with tramadol and NSAIDs. CONCLUSIONS: We believe that a computerized reporting and replying system promoted the monitoring of ADRs. Antibiotics were reported most frequently as the causative agent of ADRs. Elderly patients seemed to be more susceptible to severe ADRs. With the voluntary reporting system, skin manifestations and gastrointestinal symptoms were detected successfully, while laboratory abnormalities without prominent symptoms seemed to be overlooked. Further efforts to screen for automated ADR signals are required.