A Patient with Methemoglobinemia after Herbicide Intoxication has Hemolytic Anemia Induced by Methylene Blue

Methylene blue is the first choice for treating methemoglobinemia, any increase in normal methemoglobin levels. Methemoglobin is an abnormal hemoglobin in which the iron has been oxidized to the ferric(+3) state, making it incapable of oxygen transport. Methemoglobinemia most commonly results from exposure to oxidizing chemicals, but may also arise form genetic, dietary, or even idiopathic etiologies. Patients with low methemoglobin levels are asymptomatic, but high methemoglobin levels can lead to headaches or even death. Methylene blue, the first-line treatment for methemoglobinemia, can also produce hemolytic anemia. Jaundice or dark urine during methylene blue treatment may indicate hemolytic anemia. A 47-year-old female patient with a history of depressive mood disorder developed significant methemoglobinemia after ingesting a Propanil overdose. Twenty-two hours after ingestion, methemoglobin levels in the blood were 73.2%. She was treated with intravenous methylene blue in the therapeutic range (1 mg/kg every 4 h for 3days). The 2nd day after methylene blue use, methemoglobin levels in the blood were 33%, and the 5th day decreased to 10% with better general condition. The patient had hyperbilirubinemia after hemolytic anemia, but she recovered completely.

Korean Multicenter Study of Te tanus Antibody Titer (KoMUST)

PURPOSE: We determine the Korean antibody titer and positive rate of tetanus by using a with qualitative test (ELISA) and a quantitative test (TQS(R)). METHODS: This study was prospective collecting study with uncontolled patients who were admitted in 21 Emergency Departments during 3 months in South Korea. We measured TQS(R) and collected the serum with a centrifuge for 5 groups, which was classified with age: 2~10 years (I), 11~20 years (II), 21~30 years (III), 31~40 years (IV), 41~60 years (V), in each hospital. The freezed serum and the protocol with TQS(R) results were taken at the Soonchunhyang University Bucheon hospital to be analyzed. RESULTS: The number of enrolled patients was 1816 (male 58%). The positive rate of TQS(R) was 835 patients (46%), and there was no relation with region or sex. In sex and age, there was a definitive decline in the group III fort males and females. The results of ELISA was showed that 62.8% (> 0.15 IU/ml) and 52.2% (> 0.2 IU/ml) had protective levels of tetanus antibody. The proportion decreased to approximately 43% and 18% among persons 40~60 years of age at each level of antibody titers. By region and population, there was no statistical relationship with TQS(R) and ELISA, but previous military service was associated with a higher prevalence of protective antibodies to tetanus (p<0.001). CONCLUSIONS: A substantial portion of adults in South Korea do not have antibody levels that are protective against tetanus. Also, the mean level of tetanus antibody titers was definitively lower than those of other developed conturies and consistently decreased with aging. Therefore, an adult formulation diphteria and tetanus toxoid every 5 or 10 years is recommended for all adults between 20 and 60 years of age after being tested with TQS(R) in South Korea.

Effect of an Education Program on Violence in the Emergency Department

PURPOSE: In response to a growing threat of violence in hospitals, we examined a specific educational effort to reduce emergency department (ED) violence in the shortterm. METHODS: Cross-sectional prospective surveys were conducted at Chosun University Hospital Emergency Center during a baseline period from May 26 to Jul. 9. 2003, and during a post-education period from Aug. 7 to Sep. 20. 2003. Questions addressed the degree of violence, the reason for the violence, demographic information about the perpetrator of the violence, the outbreak time of the violence and the response of emergency personnel. RESULTS: After an education program on violence, the rate of violent events in the ED was decreased by 23.5%. A notable change was that ED workers handled the violence more positively during the post-education period by isolating or restraining the aggressor. Almost all of the violence was caused by males, particularly those in their third or fourth decade. The violence occurred mostly on the night shift. Of the violence, 52.4% was caused by the patient while 34.8% was caused by the patient's guardian. The leading causes of violence were drunkenness and delays in laboratory tests and treatment. Verbal abuse and threats were the most concern forms of violence. CONCLUSION: Violent events are frequent in the ED. Education programs may reduce the number of events at least temporarily.

Clinical Analysis of Patients Who Refused a Blood Transfusion

PURPOSE: Non-blood transfusion is of increasing interest as more patients are refusing a blood transfusion because of religious belief, infection, or fear of a blood-transmitted disease such as AIDS. This study analyzed clinical findings to help the treatment and management of patients who want a non-blood transfusion. METHODS: Of the 83 patients who visited the non-blood transfusion center in Chosun University Hospital from June 2001 to December 2003, 59 patients had a sufficient clinical record, and these were reviewed retrospectively. We investigated sex, age, the reason for the visit, the reason for refusing a blood transfusion, the degree of anemia, the necessity of the blood transfusion, the histories of transfusion and attempted non-blood transfusion, and the histories of visits to emergency departments and the outcomes. RESULTS: The male-to-female ratio was 1:2.93, and the most prevalent ages of the patients were in the forties (26 patients) and thirties (10 patients). The reasons for refusing a blood transfusion were religion (48 patients, 81.4%), risk of infection (1 patients, 1.7%), and other (10 patients, 16.9%). Among the specialty departments, the proportions of patients from the departments of obstetrics and gynecology, internal medicine, general surgery and orthopedics were 40.7% (24 patients), 25.4%, 11.9%, and 6.8%, respectively. Of the patients, 28 patients (47.5%) were admitted directly to the emergency department, and 39 patients (66.1%) were operated on. A blood transfusion was considered to be necessary for 16 patients (27.1%), but only a 2 patients (3.4%) actually received a blood transfusion. Of those 14 patients, 3patients (21.4%) died. After admission, 17 patients (29.8%) received a non-blood transfusion. CONCLUSIONS: Most of the patients visited the non-blood transfusion center for religious reasons, and the majority of the patients were admitted from the Department of Obstetrics and Gynecology. Many of the patients medically should have received blood transfusion, but only a few actually did.

Sedative Effect of Etomidate and Fentanyl by the Combinational Administration During Closed Thoracostomy

PURPOSE: As a sedative hypnotic agent, etomidate has a little side effect like respiratory depression and has an excellent pharmacokinetics and hemodynamics. The objective of this study is comparison of etomidate effect in the two groups, only lidocaine injection group and combinational administration group, during closed thoracostomy in the emergency department. METHODS: The patients with respiratory problems, which needed a closed thoracostomy, from March 1, 2003 to February 29, 2004 were enrolled in this prospective study. Thus, we were enrolled 68 patients. etomidate were used for 34 patients and only lidocaine local injection was used for 34 patients. Patients of combinational administration were randomized to receive intravenous boluses of etomidate (0.2 mg/kg) prior to fentanyl (1.0 ug/kg) during PSA (procedural sedation anesthesia). We recorded pre-administration and interval of 5 minute, 10 minute, 15 minute and transcutaneous oxygen saturation, heart rate, respiratory rate, blood pressure, degree of sedation, satisfaction of sedation, and side effects after administration. RESULTS: Of all combinational administration group, significant hemodynamic, as hypotension or bradycardia etc. and respiratory depression, as apnea or tachypnea etc. were absent. With comparison of two groups, significant clinical problems and statistics were not different and degree of sedation was fast and impaired conscious was effective in the combinational administration group. CONCLUSION: We conclude combinational administration with etomidate and fentanyl during procedural sedation is safty and excellent effectiveness. Therefore we recommened the use of etomidate for emergency procedural sedation in emergency department.

A Case of Endosulfan Intoxication Occurring in Groups

Endosulfan is an agricultural chemical of organic chlorine, is toxic in both the central nervous system and the cardiovascular system, and causes respiratory system disorder and deaths by status epilepticus, respiratory distress, and so on. The use of this agricultural chemical of organic chlorine is limited by its toxicity. However, it is still used as a common insecticide, so it is readily to available. Four elderly people were admitted with depression of consciousness and convulsions after eating pan-fried food. During their treatment, the patients were diagnosed with endosulfan intoxication, completely by accident. We are reporting these cases of endosulfan intoxication that showed variable clinical findings from mild sequelae to death.

Cyanide Poisoning after Consuming a Large Amount of Gingko Nuts

Traditionally, the gingko nut is used for enhancing liver function, skin immunity, pulmonary function, and antitussive action in chronic asthma. However, when overused, it can induce central nervous system dysfunction, and the following symptoms can manifest themselves: vomiting, dizziness, convulsion, insomnia, and confusion. We experienced a case of suspected cyanide intoxication that was manifested by convulsion and metabolic dysfunction after consuming a large number of ginko nuts. We report that case, together with a review of the literature.

Relationship between Admission and Clinical Features of Children who visited the Emergency Department with Seizures

PURPOSE: To review the seizure-related complaints and analyze the relationship between admission rates and clinical features in children who had visited the emergency department with seizures. METHODS: Retrospectively, we reviewed 180 patients(male 100, female 80) suffering from seizures, who had visited to the emergency department of Chosun University Hospital from January 2000 to June 2002. We have analyzed the correlation between admission rate and clinical features such as age, seizure type, seizure duration and individual laboratory findings(CT or MRI, and CSF). RESULTS: Out of 4,865 total children who visited the emergency department, 180 patients(3.7%) were seizure related. The most common seizure type was simple febrile seizure(52.2%). The admission rate of children with seizures was 48.9%. The admission rate according to age, sex and abnormal laboratory findings revealed no significant correlations(P>0.05). There was a significant correlation between admission and both status epilepticus 82.4%(14/17) and complex febrile seizure 63.6%(14/22) (P<0.05). According to the duration of convulsions, admission rates were 41.2% when within five minutes, 60% when six-15 minutes, 58.8% when 16-30 minutes, 85.7% when 30 minutes, to one hour and 66.7% when above one hour of duration. According to the seizure frequency, admission rates of recurrent seizure patients(61.4%=43/70) was higher compared to the first time seizure patients(40.9%=45/110). CONCLUSION: We found that the admission rate of children visiting the emergency department for seizure treatment was 48.9% and significantly correlated with duration, type and frequency of seizure.

Perception of Satisfaction with Future of 119 Rescue in the View of the User

PURPOSE: In Korea, 119 rescue plays the largest role in treating emergency patients on the scene and in transferring them to the emergency department. We wanted to find out the perception of and the satisfaction with 119 rescue, as well as its future, in the view of medical service-consumers, that is, patients and their guardians. METHODS: The subjects were patients and their guardians who came to Chosun University Hospital by means of 119 rescue between July 1 and September 31, 2002. Responders were asked their age, sex, academic background and relation to the patient. RESULTS: Perception and satisfaction - They recognized treatment on the scene (66.6%) rather then transport to the hospital (17.2%) as the most important duty of 119 rescue. Seventy percent answered that 119 rescue came to mind right away in an emergency situation, which reflects a high perception of 119 rescue. As to the time to arrive at the scene after a report, many people showed satisfaction (55%), answering that it was fast. Responsibility and rights - As to the question of whether they should hold 119 rescue responsible if the patient's condition is aggravated after treatment by 119, 48.9% answered that they shouldn't because 119 was acting with a good intention. Direction of future development - If the 119 services if to be improved, regular intensive training and testing (39.5%) intensive hospital experience (33.3%) and hiring 1st degree EMTs (27.2%) are believed to be necessary. CONCLUSION: 119 rescue was recognized as a comfortable and reliable means of emergency service. In general, most people were satisfied with the service provided by 119 rescue, but demanded experience with patient care.

Usage of Noninvasive Ventilator in the Emergency Department

PURPOSE: A general analysis of patients in the Emergency Department (ED) and the Intensive Care Unit (ICU) was performed to evaluate the effectiveness of a noninvasive ventilator (NIV) for the effective treatment of patients in respiratory distress without using endotracheal intubation. METHODS: The 38 patients who were treated with a NIV from December 1, 2001, to September 31, 2002, were studied. The ER doctors investigated prospectively sex, age, the causes of disease, the main symptoms, the duration of treatment, the mode of ventilation, the vital signs and the arterial blood gas analysis at the time of admission and after 30 minutes of NIV use, adaptation of patients, complications, and the success or failure of the treatment. RESULTS: 1) General features: Out of 38 cases, 25 males and 13 females, the average age was 60.61 years old. In group X (treatment success), the average age was significantly lower than it was in group Y (treatment failures). 2) The causes of disease and symptoms: The causes of disease were as follows: asthma and chronic obstructive pulmonary disease, 13 patients; drug intoxication, 8 patients; pulmonary edema, 8 patients; respiratory failure, 2 patients; lung contusion, 3 patients; pneumonia, 2 patients. 3) Adaptation and complications: 11 patients adapted well, 18 patients adapted normally, and 11 patients failed. Complications were minimal and included gastric distension in 2 patients and xerophthalmia in another 2. 4)Vital signs and arterial blood gas analysis results: The arterial blood gas analysis performed after 30 minutes in treatment showed improved results, but only the pH had any effect on success or failure. CONCLUSION: NIV had a success rate of 72%. The factors influencing success were surveyed according age, pH level before treatment, pH P a C O2 S a O2 30 minutes after treatment, and adaptation.

Availability of Troponin I and T and CK-MB for Diagnosis of Acute Myocardial Infarction in Patients of Renal Failure Admited to an Emergency Medical Center

PURPOSE: Generally, if a patient suffers from chest pain and shows a specific EKG pattern, it is easy to determine a clinical diagnosis, thus it is but in many cases, patients show nonspecific chest pain and a nonspecific EKG pattern. So it's important to consider the serological labaratory exam for cardiac enzymes for a definite diagnosis. Until now, cTnI has been considered to be different from CK-MB and cTnT in that it shows a specific elevation in early myocardiac injury and rare nonspecific elevation in renal-failure patients. Therefore, to affirm a sufficient relation between cTnI elevation and myocardiac injury, are carried out this study. METHODS: The number of patients in the study was 58. No one had shown any evidence of myocardiac injury during the recent 2 years or any of the risk factors for AMI, such as smoking, obesity, and hypercholesterolemia. They showed specific symptoms like chest pain or nonspecific ones like dyspnea, indigestion, or a nonspecific EKG abnormality, including nonspecific ST-T change. Their serum creatinine level was above 2.0 mg/dL and qualitative results of cTnI was obtained by using a Troponin I rapid assay kit. The definite diagnosis of AMI was made by a cardiologist based on an intergrated result of EKG, clinical symptoms and signs and regional cardiac wall-motion abnormality on a echocardiogram. RESULTS: The sensitivity of CK-MB, cTnT, and cTnI were 100%, 100%, and 100%, respectively, and the specificities were 75%, 85%, 100%. CONCLUSION: In cases of patients with a high serum-creatinine level, particularly, those with positive serum CK-MB and cTnT, the measurement of cTnI is considered to be significant for the differential diagnosis of AMI as it shows both a high sensitivity and a high specificity in early myocardiac injury.

Partial Airway Obstruction with an Armored Tube by Swelling of the Inner Layer / 대한마취과학회지

An Armored tube is known to be the most effective in maintaining of airway patency during anesthesia in any position. Unfortunately, the tube itself may become the cause of airway obstruction. One of the known complications of the armored tube is a separation of the individual latex layers. This can be caused by herniation into the lumen. Diffusion of nitrous oxide into the inner hernia considerably intensifies the obstruction. The bubbles in the tube wall arise during manufacturing as well as during resterilization. A 62-year-old man with herniation of lumbar disc herniation was intubated with a 8.0 mm armored tube for general anesthesia. 30 minutes later, we experienced signs of partial endotracheal tube obstruction including high arterial PCO2 and inspiratory pressure in prone position. Then, tube suction with catheter was done and signs was slightly improved. But, 90 minutes later, passage of suction catheter was impossible. When operation was finished, patient was turned to supine position. We exchanged the tube with another tube and found inner wall herniation into the armored tube lumen caused by layer separation.

Evaluation of the Effect Factor on Replantation and Revascularization of an Amputated Digit

PURPOSE: To find the factors influencing the immediate and late outcome of replantation and revascularization of the digits, we carried out a prospective study from 1998 to 1999 with at least a 1-year followup. Traumatic total and subtotal amputations with inadequate circulation of the digits distal to the metacarpal head were included in the study. METHODS: This study was carried out as a prospective study from 1998 to 1999 with at least a 1- year followup. The relationship between age, sex, extent of injury, type of injury, ischemic time, regular smoking, level of injury, and survival rate were analyzed. There were 234 patients with 155 males (254 digits) and 79 females (129 digits). RESULTS: Successful operation was found in 203 patients (86.3%), 314 digits (82%). Although male patients seemed to have poorer survival rates than female, it should be noted that male patients had more severe injuries than female patients. All patients who were regular cigarette smokers were males. Cigarette smoking has been shown to cause cutaneous vasoconstriction, decrease the digital blood flow, and impair the wound healing. These two reasons might explain the lower survival rate in males than in females. Type of injury significantly affected the survival rate. The survival rate was very low in extensive crushed amputation (11.1% survival rate), followed by degloving (21.1% survival rate) and avulsion (64.7% survival rate) amputation. The level of injury also seemed to determine the survival rate as injury at Zone I (65% survival rate) resulted in a poor survival rate compared to the injury at Zone II, III, or IV (92%, 97.6%, or 90.9% survival rate). Ischemic time longer than 8 hours might lessen the survival rate. CONCLUSION: All patients who had successful replantation and revascularization were satisfied with the results even though they had rather poor hand movement. In single digital replantation, no patients needed reamputation, but all preferred to have their finger replanted than udergo a primary amputation. All could accommodate and adapt their injured digits to their work.

Case Report of Tetanus Which is Treated by Human Tetanus Immunoglobulin 500 Unit

Tetanus is a neurologic disorder, characterized by increased muscle tone and spasms, that is caused by tetanospasmin, a powerful protein toxin elaborated by Clostridium tetani. In the modern society, tetanus is a rare disease, but it has a high mortality on attack and it 's diagnosis depends on the clinical symptoms. The treatment for tetanus is an injection of human tetanus immunoglobulin (HTIG) to neutralize the circulating tetanospasmin, to control breathing, and to provide systemic supportive care. Recently, the 500 unit of HTIG is recommended. We report one case of generalized tetanus that was treated with 500 units of HTIG. The patient was discharged without complications.

Case Report of a Severely Chlorophenoxy-Herbicide-Poisoned Patient Treated with Hemodialysis

Chlorophenoxy herbicide poisoning is uncommon, but may produce severe sequelae. It's treatment is primarily the same as that used for poisonings with other drugs; gastric lavage, activated charcoal, etc. However, it's secondary treatment to enhance elimination has two options, alkaline diuresis or hemodialysis. We experienced a patient who had been poisoned with chlorophenoxy herbicide and had severe symptoms like comatose mentation, acute renal failure, rhadomyolysis, etc. The patient was treated by hemodialysis for 5 days and recovered from the acute state.

The Comparative Study of Efficacy in using Midazolam and Propofol in the case of Radiology Examinations for Emergency Patients

PURPOSE: This study was performed to evaluate the usefulness of propofol in radiology studies by comparing propofol sedation with midazolam for patients who do not comply with their doctor's requests and need an injection of a sedative to be treated for a safe and quick recovery without complications. METHODS: Among adult patients who were admitted and checked using CT and MRI in our emergency medical center from February 2001 to August 2001, the patients who required sedation because of the lack of cooperation with ER doctors were studied. Of 49 patients, 23 patients (Group M) were injected with midazolam, and 26 patients (Group P) were injected with propofol. RESULTS: In both groups, the systolic BP and the diastolic BP decreased, but group P's BP decreased more than group M's (p<0.05). In group M, the decrease of SPO2 w a s statistically significant, but neither of the groups required emergency care. Although, Group M didn't require emergency care for SpO2, they did require more emergency care for apnea than Group P did. Group P's time required for an examination to be performed was shorter than group M's. Group P's duration for occurrence of movement was shorter than Group M's, but this difference was not statistically significant. Regardless of which sedative was used, there was no difference in the satisfaction of the radiology technician with regards to group M and group P. CONCLUSION: When the patients were injected with a lowdosage of propofol, they showed effects similar to those observed in patients in injected with midazolam, and there were no complications that required emergency care. The usage of propofol is thought to be a good choice, except for contraindications, for short-time radiology examinations.

Inwardly Rectifying K+ Currents in Gastric Myocytes of Guinea-pig

To identify the presence of inwardly rectifying K+ channels and its characteristics, membrane currents were measured using a whole-cell patch clamp from isolated gastric myocytes of guinea-pig. Change of external K+ concentration from 5 to 90 mM induced an inward current at a holding potential of 80 mV. The high K+-induced inward current was blocked by Ba2+ and Cs+, but not by glibenclamide. With 90 mM K+ in bath, the Ba2+- and Cs+-sensitive currents showed strong inward rectification. Ten mM TEA weakly blocked the inward current only at potentials more negative than 50 mV. With 90 mM K+ in bath, hyperpolarizing step pulses from 10 mV induced inward currents, which were inactivated at potentials more negative than 70 mV. Reduction of external K+ to 60 mM decreased the amplitudes of the currents and shifted the reversal potential to more negative potential. The inactivation of inward K+ current at negative clamp voltage was not affected by removing external Na . These results suggest that the inwardly rectifying K+ channels may exist in gastric smooth muscle.

Study of Potential Organ and Tissue Donation in the Emergency Room

BACKGROUND: It is well known that the final treatment for human organ failure is transplantation. However, in reality, the number of donors of organs is insufficient compared to the number of patients waiting for transplantation. Identification of potential organ and tissue donors is important to transplantation. The status of patients having a possibility for transplantation among the patients who visited the emergency room was reviewed, and the status of donations of organs after determination of brain death in the emergency room was reviewed. The present study was performed in order to seek methods of increasing the rate of procurement of organs. METHODS: The records of patients who visited the emergency medical center of the present hospital from January 1, 1998, to December 31, 1999, were retrospectively analyzed. The patients were classified into three groups by interviewing the doctors in charge. Group I were those who were determined to be dead upon arrival at the hospital, Group II were those who left the hospital because of death or who were hospitalized in an irrecoverable state, and Group III were those who were determined to have died during the treatment in the emergency room. RESULTS: The results of this study showed that the number of potential donors of organs among the total 33,783 patients who visited the emergency room during this time was 299 patients, including 91 patients in Group 1, 89 patients in Group 2, and 119 patients in Group 3. Among them, 137 patients were excluded as their ages were not proper, and 62 patients were excluded due to medically unsuitable diseases. The remaining 100 patients were understood to be potential organ-donating patients. Among them, 98 cases were lost as approach to transplantation was not accomplished, and only 2 cases were successful transplantations in the emergency room. The reasons for the deaths of the potential organ donors included 49 cases of trauma, 15 cases of cardiac disease, 8 cases of respiratory disease, 7 cases of cerebral vascular disease, and 11 other cases. CONCLUSION: Most patients that could be determined to be brain dead were lost without recognition of the possibility of transplantation. Although many potential organ-donating patients were seen, the actual rate of procurement of organs was very low. These results imply that it is necessary to have transplantation programs in emergency rooms in order to find patients with possible brain death and to raise the awareness and training of people engaged in medicine and of people in general. Increasing the rate of organ procurement requires that criteria for non-heart-beating donation be established and then applied in the emergency room, bearing in mind the possibility of transplantation from the time of initial treatment as serious patients. The criteria for predicting potential brain death should be prepared for prior to the determination of brain death, as presented by KONOS(Korean Network for Organ Sharing).

Related Clinical Finding Result on Complication of Tsutsugamushi Patients

BACKGROUND: Tsutsugamushi disease is an acute, rashed febrile disease that shows widely varying prognoses from unsymptomatic infection to death. Early diagnosis and treatment lead to speedy recovery. Otherwise, many complications develop. This research was carried out to analyze the factors that affect the development of complications by comparing Tsutsugamushi patients with complicaions with those without complications. METHODS: Among the acute febrile disease patients who visited the emergency center of Chosun University Hospital from January to December 2000, 41 patients were clinically and serologically confirmed as having Tsutsugamushi disease. They were divided into two groups; 14 patients with complications and 27 patients without complications. We analyzed the two groups for correlations between complications and sex, age, period of occurrence, transfer or not, vital signs, laboratory findings, period before treatment, and checks for the existence of underlying disease, eschar, eruption, chest Xrays, and early diagnosis. RESULTS: 1) The aged have a high incidence of the disease, but there was no correlation between age and complications. Also, there was no correlation based on sex. 2) Although fall has a high incidence of the disease, the other seasons have higher complication rates. 3) The complication incidence rate has no correlation with either blood pressure or heart rate, also it does no correlate with eschar and skin rashes. 4) In the laboratory findings, hemoglobin and platelet, and Bun/Cr correlate with the complicaton incidence rate, but the white blood cell count and AST/ALT do not. 5) The complication incidence rate was high when treatment was started 10 days after the onset of Tsutsugamushi disease and no early diagnosis had been given. CONCLUSION: Early diagnosis and treatment are most important in preventing complications of Tsutsugamushi disease because the factors that affect the developement of complications of Tsutsugamushi disase are found during early diagnosis. Patients with doubtful clinical symptoms and abnormal lab findings should be started on a program of antibiotic treatment.

Subclavian Artery Aneurysm due to Takayasu's Arteritis

Takayasu's arteritis is a non-specific inflammatory process that involves the aorta and its main branches, the etiology of which remains unknown. This arteritis occurs predominantly in young Asian women, although there have been many documented cases in males and non-Asians. Criteria for the diagnosis of Takayasu's arteritis were developed by The Subcommittee on Classification of Vasculitis of the American College of Rheumatology in 1990, of which a modified version is shown in Table 1. The presence of three or more of the six criteria shown demonstrated a diagnostic sensitivity of 90.5% and a specificity of 97.8%. Takayasu's arteritis is known as 'pulseless disease,' and this non-specific inflammatory arteriopathy typically produces segmental arterial narrowing and occlusion with resultant end-organ ischemic consequences, including upper extremity digital necrosis, stroke, visceral ischemia and renal failure. Previously reported sites of aneurysm formation include the thoracic and abdominal aorta, as well as the innominate, the carotid and the superior mesenteric arteries, but rarely the subclavian artery. A 26-year-old man presented with a progressively enlarging and tender pulsatile mass at the base of the left neck, intermittent Claudication of the upper limbs in association with a decreased brachial artery pulse and a bruit over the subclavian artery. Computed tomography and aortography demonstrated a 4 cmX5 cm aneurysm of the left subclavian artery. There was no evidence of occlusive disease. An aneurysmectomy with 8 mm hemashield graft interposis was performed . Pathology revealed a chronic, active inflammatory process. Aneurysm formation is an unusual complication of Takayasu's arteritis. Emergency department physicians must carefully observed patiens with symptomatic upper extremity pain and paresthesia and must consider whether those symptoms might be due to the formation of a subclavian artery aneurysm due to Takayasu's arteritis