A Case of Late Mixed Acute Humoral and Cellular Rejection Successfully Treated with Rituximab, Plasmapheresis and IVIg / 대한이식학회지

Acute antibody-mediated rejection (AMR) developing simultaneously with acute cellular rejection has been rarely reported as a long-term complication of renal transplantation, and it can present on top of another chronic pathology affecting the graft. A 51-year-old female patient with chronic kidney disease of unknown etiology received renal transplantation 12 years ago from a living unrelated donor with 3 HLA mismatches. She received induction therapy with methylprednisolone and was maintained on steroids, mycophenolate mofetil and cyclosporine A (CsA). For a period of twelve years post-transplantation, she was clinically and biochemically stable. She presented with a rise in serum creatinine (SCr.) from 1.3 mg/dL to 2.4 mg/dL but did not have proteinuria. Graft biopsy revealed findings suggestive of acute cellular rejection on top of antibody-mediated rejection (type II) and chronic calcineurin inhibitor toxicity. Panel reactive antibody (PRA) test levels were 3.6%, 91.7% for class I and II respectively. The patient was treated with high-dose methylprednisolone for 3 days but serum creatinine was not fully normalised. After 2 weeks from initial methyl-PDS pulse therapy, she received intravenous immunoglobulin, plasma exchange and anti-CD20 (rituximab). Cyclosporine was changed to tacrolimus. She achieved a complete response, and SCr. was maintained at 1.3 mg/dL without proteinuria. Follow-up PRA test levels were 0%, 75% for class I and II. Current therapies have had considerable success in reversing mixed, acute humoral and cellular rejection since it is being identified quickly and treated aggressively. The best use of rituximab to treat AMR should be evaluated in controlled trials using dosing strategies that include longer courses or retreatment schedules.

A Case of Retransplantation in A Patient with Graft Loss Caused by Polyoma Virus Nephropathy / 대한신장학회잡지

Polyoma virus (PV) nephropathy is a known cause of graft loss after renal transplantation. In a renal transplant patient suspected of graft rejection, it is important to discriminate between PV induced interstitial nephritis and acute cellular rejection, because of similar pathologic findings. After the loss of the first allograft secondary to PV nephropathy, transplant graft nephroureterectomy before retransplantaton may have an influence in the recurrence of PV nephropathy. However, this question has not been completely resolved. Case: A 23-year-old male underwent first renal transplantation from his HLA haploidentical 25 year-old-sister. His renal function had been good with cyclosporine, steroid and azathioprine until 9 months after transplantation, when his serum creatinine level rose to 2.2 mg/dL. A renal biopsy revealed features of tubulitis and we confirmed PV nephropathy through a positive PV monoclonal antibody reaction to inclusion body. After gradual loss of graft function, he underwent hemodialysis. After 48 months of hemodialysis, the patient underwent cadaveric renal retransplantation without transplant graft nephroureterectomy. Thrombocytopenia and suspected delayed graft function occurred after 2 days of transplantation. A graft biopsy revealed thrombotic microangiopathy. Improved graft function was attained after a temporary stop of tacrolimus and ATGAM(R) bridging therapy. The patient is maintaining satisfactory graft function 33 months after retransplantation without clinical and serological evidence of recurrent PV infection.

A Case of Nocardiosis with CMV (Cytomegalovirus) Infection after Third Renal Transplantation in China / 대한이식학회지

It has been well known that long-term immune suppression in renal transplant patients increases the possibility of complications. Infectious disease is one of the representative complications. We experienced a case of nocardiosis with cytomegalovirus infection after third renal transplantation in China. Nocardiosis is an important opportunistic infection in immunosuppressed patients, lymphoma, sarcoidosis, and organ transplant patients. CMV can cause severe hepatitis, pneumonitis, enteritis, endometritis, and encephalitis. It can depress bone marrow, and impair the immune system so as to increase other bacterial infection and trigger rejections. Third renal transplantation causes long-term immune suppression or over-immune suppression on transplant patients. Very few cases of third renal transplantation have been reported in Korea. We reduced the dose of immune- suppressants, and treated it successfully with ganciclovir and Trimethoprim/Sulfamethoxazole (Bactrim(R)).

The Clinical Analysis of Bleeding Pattern in Patients with Ruptured Middle Cerebral Artery Aneurysm

OBJECTIVES: The rupture of middle cerebral artery(MCA) aneurysm usually cause or is associated with higher incidence of intracerebral hemorrhages(ICH) than any other aneurysmal ruptures. Also, the outcome of patients who had ICH is known to be worse than patients who had subarachnoid hemorrhage(SAH) only. The authors report the bleeding pattern and outcome of ruptured MCA aneurysm patients. PATIENTS AND METHODS: A total 106 ruptured MCA aneurysm patients who were surgically treated were included and they were divided into 2 groups by the initial brain CT findings according to the presence or absence of ICH over 10cc in amount. The clinical data were analysed retrospectively. RESULTS: The overall mortality was 18.9%. Among 81 patients(76.4%) who had subarachnoid hemorrhage(SAH) only, 68 patients(84%) showed favorable outcome. Twenty five patients(23.6%) had ICH over 10cc in amount with or without SAH, and among them, 11 patients(44%) showed favorable outcome. The ICH was located in temporal lobe(15 patients, 60%), frontal lobe(3, 12%), sylvian fissure(6, 24%) and frontal-temporal lobe(1, 4%). Among 15 patients who had ICH in temporal lobe, only 4 patients(26.6%) showed favorable outcome and all 3 patients who had ICH in frontal lobe showed favorable outcome. CONCLUSION: ICH was presented in 23.6% of ruptured MCA aneurysm patients and the prognosis of patients with ICH was worse than patients with SAH only. The ICH was located mainly in the temporal lobe and sylvian fissure.

Subarachnoid Space Reconstruction for Treatment of Posttraymatic Syringomyelia

No abstract available.

Pyogenic Spondylitis with Diffuse Spinal Epidural Abscess: A Case Report

No abstract available.

Rapid Spontaneous Resolution of Acute Subdural Hematoma

Usually, large amount of acute subdural hematoma needs prompt surgical removal. We report a case of rapid spontaneous resolution in a day. A 78-old female was admitted in comatose state after falling off from a bus. Initial brain CT scan revealed large amount of acute subdural hematoma that was completely resolved on follow-up brain CT taken 26hours after craniocerebral trauma. The spontaneous resolution needs redistribution of hematoma and dilution by CSF. The low density space between inner skull table and hematoma may suggest the possibility of spontaneous resolution.

Effect of Decompressive Surgery on Neurological Outcome Following Incomplete Cord Injury of the Mid and Lower Cervical Spines

To determine the effects of decompressive surgery on neurological outcome following incomplete cord injury of the mid and lower cervical spines, 44 patients(decompression and stabilization group: stabilization or conservative treatment group=21:23) who underwent operations between 1993 and 1995 were retrospectively reviewed. We compared neurological outcome by Frankel's grade, Prolo economic and functional rating scale, and final ambulatory status between two groups. Also, we analysed MRI findings related to neurologic outcome in these cervical cord injured patients. With regard to upgrading scale by Frankel's grade, decompressive surgery group was more improved(98% vs 78%). With regard to Prolo's scale, decompressive surgery group were excellent in 24%, good in 52%, and fair in 24%. Stabilization only or conservative treatment group were as follows: excellent(22%), good(39%), fair(30%), and poor (9%). In the viewpoint of walking status, the result of decompressive surgery group was better(90% vs 74%). Initial MRI findings and neurological assesment correlated with neurological recovery. In conclusion, decompressive surgery may be more effective in patients with incomplete cord injury on mid or lower cervical spines when there are cord compressive lesions such as traumatic disc herniation, spondylotic spur, bony impingement in the spinal canal, and irreducible spinal malalignment unless major intramedullary hemorrhage is present.

Chronic Spinal Epidural Hematoma after Herniated Lumbar Disc Surgery: A Case Report

We report a case of chronic spinal epidural hematoma in a 21-year old male who was operated on his back due to herniated lumbar disc at the right side of L5-S1 level. The postoperative MRI demonstrated isointense mass on T1W1 and hyperintense on T2W1 at the point where the initial herniated disc compressed the right S1 root. Revision was done and the mass was disclosed to be well-encapsulated chronic spinal epidural hematoma and here-by we report the case with review of literature.

Clinical Outcome of Surgical Treatment with Instrumentation and Fusion in the Management of the Thoracolumbar Injured Patients

The goals of operation for unstable thoracolumbar spine injuries are decompression of any neural canal compression, restoration of normal anatomic contour of the spine and stabilization. A retrospective analysis on 64 thoracolumbar injured patients treated with internal instrumentation and fusion was performed from January 1991 to December 1996. The purpose of this study was to review the clinical outcome and efficacy of surgical treatment using internal instrumentation, and compare neurological, radiological and functional outcomes between anterior and posterior approach groups. Of these, 42 patients were operated via on posterior approaches and the other 22 patients by anterior approaches. At final follow up evaluation with mean period of 14.5 months, 50 patients(78%) were walking and 47 patients(92%) except 4 patients(A-A, three and C-C one patient) had improved using Frankel's grade in patients with neurological deficits(51 patients). No patient deteriorated. Radiological and functional outcomes were satisfactory in the majority of patients. In a comparison of the clinical outcomes between anterior and posterior approaches, there was no statistically significant difference in neurological outcome(the mean value of up-grade: anterior 1.05+/-.7, posterior 0.95+/-.9, p=0.42), but in radiological outcomes, there were no significant differences between the two groups in amount of restoration of vertebral compression(mean recovery rate: anterior 61.5%, posterior 50.9%), kyphotic deformity(mean recovery rate: anterior 47.9%, posterior 70.0%)(p>0.05), but the only difference was in the restoration of canal narrowing, with the anterior group more improved(recovery rate: anterior 86.4%, posterior 74.3%) (p<0.05). In functional outcomes by Prolo's scale, the anterior group was better than the posterior group(mean economic and functional status: anterior E(4.4), F(4.3); posterior E(3.5),F(3.9)). We conclude that agressive decompression, instrumentation and bone fusion has shown better clinical outcomes of the unstable thoracolumbar injured patients and the choice of surgical approaches depends on the general condition, age, status of bone mineral density, specific injury mechanism, radiological findings, and grade of neural injury at the time of injury of these patients.

Clinical Study of Inguinal Hernia in Children

A total of 335 inguinal hernias in children were analyzed by the authors at the Department of General Surgery, St. Benedict Hospital, for last 10 years, from 1986 to 1995. The male patients were predominant (2.25:1), and 78.2% were under 2 years of age. Right side was 1.63 times more frequent than the left. Among the 19 cases of incarcerated hernias, 84% could be reduced preoperatively in safe. Only 3.6% of the cases were repaired by Bassini procedure, but the others didn't require posterior wall reconstruction. Bilaterality was 25 cases (7.5%), and 8 cases (2.4%) developed later contralateral hernias after primary ipsilateral fix. Complications were in 15 cases (4.5%) such as scrotal seroma and/or hematoma (3%), wound infection (0.6%), pneumonia (0.9%). For the more comprehensive care for the herniated children, specialized practice by a pediatric surgeon would be required in the future.

Scalp Defect, Injuries of Skull and Brain Parenchyme Caused by High Voltage Electrical Burn: A Case Report

The authors describe a case of accidental eletrical injury from high voltage direct current in a young worker, who was struck by the electric shock in the left occipito-parietal region. This case is interesting due to the development of left ooccipito-parietal parenchymal brain lesion with transient anomic aphasia and visual disturbances. We believe that is first report on parenchymal brain injury due to high voltage electrical burn confirmed pathologically in Korea. The patient had full thickness scalp defect, skull necrosis, and parenchymal brain injury. We performed one stage brain and dural biopsy with split rib graft cranioplasty after removal of devitalized skull and scalp flap surgery. The clinical presentation, radiological, pathological finding, and outcome are reviewed.

A Clinical Analysis of the Patients Who "Talk and Deteriorate" as a Result of Delayed Traumatic Intracerebral Hematomas

During a six-year period, 15 cases of "Talk and Deteriorate"patients who were suffering from delayed traumatic intracerebral hematoma(DTICH) were found retrospectively among 1055 patients with head injuries. All fifteen had suffered initial mild head injury(GCS score, 13-15), and apoplectic events or progressive neurological deficits(GCS<8) requiring surgical intervention developed within 72 hours. Subsequent CT scanning showed worsening of the original contusional lesion in ten cases, new hematoma in six, and new lesion(contusion, ischemia and/or edema) in five. cases. The most common location of DTICH was the frontal lobe(11 cases) and the most common cause of injury was a fall(10 cases). The condition of most of these patients could not be predicted, and there was no clear evidence of secondary insults such as hypoxia, hypotension, anemia, or hypercarbia, but hyperglycemia and coagulopathy were seen. Our results demonstrated that in spite of an initially high GCS score, patients who had been injured during a fall and on initial CT scan showed frontal lobe hemorrhagic contusion and/or swelling should be observed closely for at least three days after the injury. Among patients in the "Talk and Deteriorate"group whose condition was caused by DTICH, early diagnosis and aggressive treatment may be the most important life-saving management strategy.

The Several Measurements and Results of Plain Skull X-ray in Korean Adults

The measurements of skull in roentgenogram were made in 234 cases of korean adults, 128 male and 106 female. Results were obtained as follows. The Cephalic index was 84.7 in male, 84 in female, and 84.09 in both gender. The result was greater than other reported results. The Anterior-Posterior(AP) diameter of pituitary fossa was 1.19+/-0.14cm in male, 1.21+/-0.16cm in female and 1.20+/-0.15cm in both gender. The result was greater than other results. The depth of pituitary fossa was 1.00+/-0.13cm in male 0.99+/-0.12cm in female and 1.20+/-0.99cm in both gender. The mean value of AP diameter and depth of pituitary fossa was greater than the other reported results. The Basal Angle was 127.20+/-5.23 in male, 127.86+/-5.07 in female and 127.50+/-5.21 in both gender, which were smaller than other results. The sphenoid type was classified into 3 types as sella, presella, and concha. The percentage of each type was : sella type with 78%, presella type with 20%, and concha type in 2%. The pineal gland calcification rate in korean adults was lower than that of Westerners. The occurance of Metopic suture and Mendosal suture in simple skull X-ray was rare. We believe the above measurement will provide helpful information in planning a surgical approach as well as in understanding the data discrepancies between skulls of the Asian and European populations.

A Surgical Experience of a Odontoid Type II Fracture by Transoral Approach and Internal Fixation with Screws and Mini-plate

With changing mechanisms of injury, heightened clinical awareness, and better diagnostic technology, odontoid fractures constitute 9~18% of cervical fractures in recent reports. The odontoid type II fracture is the most common axis fracture and it is also the most difficult to treat. Type II fractures with greater than 6mm dens dislocation have a higher incidence of nonunion with nonoperative therapy and should be offered early operative reduction with fusion. Recently we have experienced a young male patient with odontoid type II fracture. The degree of dens dislocation was 8mm. The fractured odontoid process was removed through transoral-transpharyngeal approach and bone fusion was performed with iliac bone. And the inserted bone was fixed with screws and mini-plate for further stabilization. The operative result was good without any serious complications. The operation technique is detailed.

The clinical case report of echinococcal cyst of the liver caused by echinococcus granulous

No abstract available.

Anterolateral Instrumentation and Spinal Stabilization in the Treatment of Fractures of the Thoracolumbar Area

In the treatment of fractures of the thoracolumbar junctiion area, surgical intervention was performed when posterior part of veretbral body, posterior structure supporting ligaments were involved and body compression more than 40%. Number of cases satisfying above criteria were seven between Aug. 1990 and Jun. 1991. Age distribution ranged from 15 to 57 years. Sex ratio was 4:3(F:M). Four patients presented with nerve root sign, one patient with cauda equina signs, and two patients were normal neurologically. In all cases, spinal canal decompression, internal instrument fixation, and bone fusion with iliac bone were performed via anterolateral approach. After surgical treatment, neurological deficits disappeared and kyphotic angle returned to normal range of thoracolumbar junction area in all cases. Percentage of body compression was improved from preop. 55% to postop. 21% in average. According to above results, we concluded that anterior instrumental fixation combined with bone fusion using iliac bone was supperior to posterior approach in providing biomechanical stability and decompression of protruding ventral bone fragments.