Korean guidelines for the management of gout

Gout is the most common form of arthritis, with the prevalence increasing worldwide. The present treatment guidelines provide recommendations for the appropriate treatment of acute gout, management during the inter-critical period, and prevention of chronic complications. The guidelines were developed based on evidence-based medicine and draft recommendations finalized after expert consensus. These guidelines are designed to provide clinicians with clinical evidence to enable efficient treatment of gout.

Korean guidelines for the management of gout

Gout is the most common form of arthritis, with the prevalence increasing worldwide. The present treatment guidelines provide recommendations for the appropriate treatment of acute gout, management during the inter-critical period, and prevention of chronic complications. The guidelines were developed based on evidence-based medicine and draft recommendations finalized after expert consensus. These guidelines are designed to provide clinicians with clinical evidence to enable efficient treatment of gout.

Plasmodium vivax Infection in a Patient with Systemic Lupus Erythematosus / 대한류마티스학회지

Malaria was rarely reported in patients with systemic lupus erythematosus (SLE). We report a case of P. vivax infection in a patient with SLE. A 42-year-old woman was admitted to the hospital because of fever, anemia, and severe thrombocytopenia and had transfusion of multiple blood products including 16 units of red blood cells (RBC). The patient was diagnosed as having SLE complicated with antiphospholipid syndrome. From the 96th hospital day, the patient had cyclic high fever for 4~5 hours, myalgia and shaking chills, follwed by generalized diaphoresis and resolution of fever. Examination of her peripheral blood smear showed gametocytes of P. vivax. She received hydroxychloroquine of a total dose of 25 mg/kg orally over 3 days and then oral primaquine 15 mg/day for 14 days. Blood donors were traced retrospectively. The 13 RBC products were negative for malaria but other three RBC products could not be checked on P. vivax. The patient was presumed to have acquired malaria from infected blood products. Relapse did not occur 1 year later. In conclusion, malaria should be considered in the differential diagnosis of persistent fever in a patients with SLE who received multiple blood products in Korea.

Prosthetic valve endocarditis manifesting multiple huge aspergilloma / 대한내과학회지

Fungal prosthetic valve endocarditis is a rare, poo-prognostic disease. The risk factors for fungal valve endocardits are open heart surgery, hyperalimentation, antibiotic therapy, IV drug abuse, concomitant bacterial endocarditis and immunosuppression. We report a case of aspergillus endocarditis in the aortic valve, which extended to ascending aorta after Redo-aortic valve replacement surgery. A 22-year-old male patient underwent Redo-aortic valve replacement surgery with 23mm-sized Sorin valve(bi-leaflet tilting disc valve) due to prosthetic valve failure. He was readmitted because of development of cough, anorexia, fatigue and fever after operation. The results of repeated blood culture were negative, and the symptoms continued in spite of 2 week treatment with broad spectrum antibiotics. Echocardiography and spiral computed tomographic angiography revealed multiple, huge masses in the aortic valve extending to ascending aorta. Emergent surgery was performed. Infected valve and surrounding areas were widely excised and aortic homograft was inserted. Resected aorta and prosthetic valve showed multiple mass-forming vegetations, measuring up to 4cmx3cmx3cm. Microscopically, they revealed fungal organisms, showing sharp-angle branching and septate hyphae. Aspergillus flavus was isolated in culture of resected tissue. The patient suddenly died of ventricular fibrillation 3 weeks after surgery in spite of treatement with intravenous amphotericin B.

The Clinical Usefulness of Spiral CT Angiography in the Diagnosis of Pulmonary Thromboembolism / 결핵

BACKGROUND: Pulmonary thromboembolism(PTE) is a life threatening disease that needs early diagnosis. Spiral CT angiography depict thromboemboli in the central pulmonary vessels with greater than 90% sensitivity and specificity, which approaches the results of pulmonary angiography in the Prospective Investigation of Pulmonary value(clinical utility) of the spiral CT angiography with 2D image (multiplanar reformation) and 3D images(Shaded surface display, Minimal intensity projection) in the pulmonary thromboembolism. METHODS: We retrospectively analysed spiral CT angiography and prlmonary angiography, lung scan and clinical recordings of 20 patients who had PTE diagnosed by spiral CT angiography(n=19 cases) or pulmonary angiography(n=1 case) from September 1997 to August 1998. Among 20 patients who had underwent spiral CT angiography, 14 patients could be performed lung perfusion scan at the same time. We analyzed the vascular and parenchymal change in spiral CT angiogram. RESULTS: Anatomical distribution of PTE was as follows : 1) left lung(n=103) < right lung(n=129), 2) upper and middle(or lingular) lobe(n=101) < lower lobe(n=116), 3) proximal < distal but 5th order in lower lobe was decreased in distribution. Spiral CT angiography could allow accurate demonstration of 19/20 cases(95%) PTE in our study. Spiral CT angiography could demonstrate acute PTE in 16 patients and chronic PTE in 3 patients. Spiral CT angiography could also showed the combined lung parenchymal lesions(Infarction(n=9 cases), atelectasis(n=4 cases), pleural effusion(n=6 cases)). CONCLUSIONS: Spiral CT angiography with 2D image (multiplanar reformation) and 3D images(shaded surface display, minimal intensity projection) is a noninvasive diagnostic tool in the pulmonary thromboembolism. This method had several advantages; 1) It was showed the distribution of pulmonary embolism in total lung field. 2) It had high sensitivity in diagnosis of pulmonary embolism. 3) It discriminated between acute and chronic PTE. 4) It was showed the associated disease such as lung infarction, atelectasis, pleural effusion. 5) It was correlated with scintigraphic findings.

A Case of Osteogenesis Imperfecta associated with Aortic Regurgitation / 대한내과학회지

Osteogenesis imperfecta is one of the groups of hereditary disorders of connective tissue which includes the Ehlers-Danlos syndrome, the Marfan syndrome, pseudoxanthoma elasticum, and Hurler syndrome. While cardiovascular involvement is associated with each of these disorders, it is least common in osteogenesis imperfecta and is overshadowed by the bony, ocular, otologic, cutaneous, and dental manifestations that are characteristic of the disorder. In evaluating patients with osteogenesis imperfecta, careful attention should be paid to cardiovascular findings and if valvular lesions are noted, patients should be instructed regarding the need for antibiotic prophylaxis for dental and surgical procedures. We report a case of osteogenesis imperfecta associated with aortic regurgitation.

A Case of Scimiter Syndrome (Adult Form) / 결핵

The scimitar syndrome, a rare complex anomaly, is defined as an anomalous right pulmonary venous drainage, partial or complete, to the inferior versa cava. The shape of the Turkish curved sword (scimitar) huts provided the name of this syndrome. Additional characteristics of this syndrome such as hypoplasia of the right lung and of the right pulmonary arterial tree, anomalous arterial supply of the right lung from the aorta, dextrocardia and bronchial anomalies are common. Recently we experienced a case of scimitar syndrome (adult form) in a 19-year-old woman patient, so we report the case with a brief review of the literature.

Two Cases of Chiari Network

A network of strands (Chiari Network) in the right atrium with attachments extending from the crista terminalis to eustachian valve and thebesian valve or sometimes to the floor of the right atrium in the region of the opening of the coronary sinus. While this congenital remnant is seldom clinically important, this membranes have been reported as site of thombus formation, and hence potential etiologies of pulmonary emboli as well as a source of entrapment of a right-heart catheter and arrhythmia. We report two cases of right atrial mass-like chiari form network incidentally detected by transthoracic echocardiography (TTE) and confirmed by transesophageal echocardiography (TEE).

A Case of Atrial Septal Aneurysm Associated with Multiple Renal Infarction

Atrial septal aneurysm (ASA) was reported as a cause of unknown origin of central or peripheral thromboembolism with patent foramen ovale, aortic debris and spontaneous echo contrast. Especially the paradoxical right to left shunt via micro-fenestration on this sac may be the important cause of this embolism. We report a case of 39 year-old female patient who had atrial septal aneurysm with multiple renal infarction. Symptom was improved with aneurysmectomy and patch closure, then long term anticoagulation has been continued.

Aspiration Thromboembolectomy in the Management of Acute Coronary Occlusion during Pertaneous Transluminal Coronary Angioplasty

Percutaneous transluminal coronary angioplasty (PTCA) is often used in the management of coronary artery disease and the advances in equipment, technichal skill and acquisition of operator experiences have improved initial success rates and reduced the frequency of complications. However, acute coronary occlusion is the most common and serious complication related to angioplasty and its several potential mechanisms are intracoronary thrombus, coronary artery spasm and coronary artery dissection. Accordingly,heparinization, intracoronary thrombolysis, re-PTCA, stent implantation and emergency coronary artery bypass grafting have been previously used for reopening of an occluded coronary artery during angioplasty. In this report we describe our experience in the management of acute coronary occlusion of left anterior descending artery caused by dislodgement of thrombotic material during PTCA by means of aspiration thromboembolectomy instead of medical therapy,re-PTCA and stent implantation.

A Case of Takayasu's Arteritis Presented by Stenosis of Main Pulmonary Artery and Obstruction of the Right Coronary Artery / 대한내과학회지

Takayasu's arteritis is generally recognized as a chronic, idiopathic, inflammatory disease, which affects the aorta and the proximal portions of its major branches. We experienced a patient with Takayasu's arteritis who was presented with main pulmonary artery stenosis and right coronary ostial occlusion without involvement of aorta nor its major branches. She was managed with pulmonary arterioplasty and coronary artery bypass graft. This case emphasize that the disease cannot affect the aorta.

Percutaneous Mitral Balloon Valveloplasty after Successful Resolution of Left Atrial Appendage Thrombi by Oral Anticoagulation

OBJECTIVE: Systemic embolism related with left atrial thrombi is a well known complication of percutaneous ballon valveloplasty of the mitral valve stenosis. The presence of left atrial thtombi is believed to be a contraindication to balloon valvuloplasty. The purpose of this study was to determine whether balloon valvuloplasty is possible in mitral stenosis patients with left atrial thrombi after oral anticoagulation therapy. METHODS: We studied 13 consecutive patients(12 : female, 1 : male, mean age : 44+/-11) who had mitral stenosis and left atrial appendage thrombi by serial transesophageal echocardiography before balloon valvuloplasty of the stenotic mitral valve from May 1995 to January 1997. We started oral anticoagulation in those 13 patients with mitral stenosis and left atrial appendage thrombi to keep the INR 2-3. Regular follow up was performed by transesophageal echocardiagraphy to determine whether the left atrial appendage thrombi are resolved. Patients underwent percutaneous balloon valvuloplasty after complete resolution of left atrial appendage thrombi. RESULTS: 9 patients(69.2%) underwent balloon valvuloplasty after complete resolution of left atrial appendage thrombi with oral anticoagulation for average 6 months. Two (15.4%) patients had normal sinus rhythm. Three patients had coronary A-V fistular due to neovascularization to left atrial appendage thrombi. In four patients, oral antiocoagulation failed to resolve the left atrial appendage thrombi and they underwent balloon valvuloplasty under TEE guide with special caution to avoid systemic embolization. There were no complications such as systemic embolization in those 4 patients. CONCLUSION: Left atrial appendage thrombi in mitral stenosis could be resolved in high proportion(69.2%) by oral anticoagulation therapy. Percutaneous mitral balloon valvuloplasty could be a safe and effective treatment modality despite of the presence of left atrial appendage thrombi after adequate oral anticoagulation therapy.