Emphysematous Gastritis with Concomitant Portal Venous Air and Acute Necrotizing Esophagitis in Type 1 Diabetes with Diabetic Ketoacidosis: A Case Report and Literature Review of a Rare Complication in Diabetes / 임상당뇨병

Emphysematous gastritis is a rare disorder characterized by emphysematous change of the gastric wall due to infection with a gas-forming organism. Acute necrotizing esophagitis is a rare disorder with an unknown pathogenesis. Above two disorders rarely occur together, only three global cases have been reported to date. Such a case has never been reported in Korea, we report a novel case of severe emphysematous gastritis with concomitant portal venous air and acute necrotizing esophagitis in type 1 diabetes presenting with diabetic ketoacidosis. A 24-year-old man known to have type 1 diabetes and pulmonary tuberculosis was brought to the emergency room for epigastric pain with vomiting. His body mass index was 14.7, and the laboratory findings demonstrated leukocytosis and acidosis, as well as elevated serum glucose, ketone, and C-reactive protein levels. Enhanced computed tomography showed portal vein gas and edematous wall thickening without enhancement in the stomach wall, with air density along the stomach and esophageal wall. The patient required surgical intervention of total gastrectomy and cervical esophagostomy followed by esophagocolostomy and esophageal reconstruction. Early radiologic diagnosis and clinical suspicion of this disease and prompt intervention including antibiotics, decompression, and surgery are important for a good prognosis.

The effects of sarcopenia and obesity on femur neck bone mineral density in elderly Korean men and women

OBJECTIVE: We aimed to clarify the relationship between fat, muscle, and bone in elderly men and women. METHODS: We analyzed 1373 men and 1803 women who were older than 65 years from the 2008-2010 Korea National Health and Nutritional Examination Surveys. Body composition and femur neck bone mineral density (BMD) were measured by dual-energy X-ray absorptiometry. Sarcopenia was defined as an appendicular skeletal muscle index (SMI) below one standard deviation (SD). Obesity was classified by fat mass index (FMI). Osteoporosis was defined as a BMD of 2.5 SD below that of femur neck BMD. RESULTS: SMI and FMI were positively correlated with femur neck BMD. In multiple regression analysis, SMI (β = 0.302 in men, β = 0.154 in women; p < 0.001 each) and FMI (β = 0.079 in men, β = 0.179 in women; p = 0.003 and p < 0.001 respectively) had a positive relationship with femur neck BMD. Men with sarcopenia were 3.89 times more likely to develop osteoporosis. Women with sarcopenia were 1.87 times more likely to develop osteoporosis. Sarcopenia was more clinically significant in the development of osteoporosis in men with a fat deficit and women with excess fat CONCLUSIONS: Muscle mass and fat mass were identified as determinants of femur neck BMD in men and women. Among them, muscle mass of men and fat mass of women are the most important determinants of femur neck osteoporosis.

Partial Androgen Insensitivity Syndrome Presenting with Gynecomastia

Gynecomastia is a benign enlargement of the male breast caused by the proliferation of glandular breast tissue. Determining the various causes of gynecomastia such as physiological causes, drugs, systemic diseases, and endocrine disorders is important. Androgen insensitivity syndrome (AIS) is a rare endocrine disorder presenting with gynecomastia and is a disorder of male sexual differentiation caused by mutations within the androgen receptor gene. All individuals with AIS have the 46 XY karyotype, although AIS phenotypes can be classified as mild, partial or complete and can differ among both males and females including ambiguous genitalia or infertility in males. We experienced a case of partial AIS presenting with gynecomastia and identified the androgen receptor gene mutation.

Hyperinsulinemic Hypoglycemia Caused by Acute Reduction of Renal Function on an Eldery Patient Without Diabetes

In patient with renal failure, hypoglycemia may develop because of decreased caloric intake, diminished renal insulin degradation and clearance, reduced renal gluconeogenesis and hepatic glucose production, impaired release of counter-regulatory hormone such as glucagon and epinephrine. We report here on a 80-year-old female patient with hypoglycemia due to endogenous hyperinsulinemia with acute kidney injury. She had chronic kidney disease and had no history of diabetes mellitus or insulin use. She had experienced recurrent hypoglycemia despite of intravenous dextrose injection and eventually generalized tonic clonic seizure occurred as a result of hypoglycemia. As serum creatinine level decreases, serum insulin and C-peptide level decreased and hypoglycemia was not occurred. We present this case along with a review of the literature.

A Case of Acute Suppurative Thyroiditis with Thyrotoxicosis in an Elderly Patient

Acute suppurative thyroiditis (AST) is a rare condition, as the thyroid gland is relatively resistant to infection. Thyroid function tests are usually normal in AST. A few cases of AST associated with thyrotoxicosis have been reported in adults. We report a case of AST that was associated with thyrotoxicosis in a 70-year-old woman. We diagnosed AST with thyroid ultrasonography and fine needle aspiration of pus. The patient improved after surgical intervention and had no anatomical abnormality. Fine needle aspiration is the best method for the difficult task of differentiating malignancy and subacute thyroiditis from AST with thyrotoxicosis. Earlier diagnosis and proper treatment for AST might improve the outcome.

A Case of Metformin-Induced Acute Kidney Injury without Lactic Acidosis: A Case Report / 대한구급학회지

Metformin is an oral antidiabetic drug in the biguanide class, which is used for type 2 diabetes. The side effects of metformin are mostly limited to digestive tract symptoms, such as diarrhea, flatulence and abdominal discomfort. The most serious potential adverse effect of metformin is lactic acidosis. A 51-year-old man was admitted due to hypoglycemia as a result of an overdose of antidiabetic drugs. He took massive dose of metformin. Conservative treatment failed for metabolic acidosis without lactic acidosis accompanied by acute kidney injury. Hemodialysis was executed to correct the high anion gap metabolic acidosis and acute kidney injury, and the patient recovered fully from metabolic acidosis. This case illustrates that the presence of clinical conditions, such as metformin-induced acute kidney injury and metabolic acidosis, can be developed without lactic acidosis. Prompt recognition of metabolic acidosis and early intervention with hemodialysis can result in a successful clinical outcome.

Clinical and Physiopathological Mechanism of Sarcopenia / 대한내과학회지

Sarcopenia is defined the loss of muscle mass and strength with aging. Although the etiology and the pathogenesis, the diagnosis of sarcopenia are obscure, the sequel of sarcopenia, i.e. morbidity and mortality, metabolic complications, are a major public health problem. Particularly, aged people in Korea are increasing rapidly more than expected; therefore the interest of sarcopenia is also increasing rapidly. This article provides an overview of the pathogenesis, and diagnosis, epidemiology, clinical results.

Characteristics of Body Fat, Body Fat Percentage and Other Body Composition for Koreans from KNHANES IV

Accurate measurement of fat mass has become increasingly important with the increasing incidence of obesity. We assessed fat and muscle mass of Koreans with the Korea National Health and Nutrition Examination Survey IV (KNHANES IV). We studied 10,456 subjects (aged 20 to 85 yr; 4,476 men, 5,980 women). Fat and muscle mass were measured by dual-energy x-ray absorptiometry. Reference values of body compositions were obtained using the LMS method. The fat mass index (FMI, body fat mass/height2; kg/m2) of Korean men did not correlate with age (P = 0.452), but those of Korean women (P 9 kg/m2) in men and 2.7% (FMI > 13 kg/m2) in women. It is concluded that the muscle mass decreases and obesity increases with aging in Korean men, whereas both fat mass and obesity increase with aging in Korean women.

The Relationship between Diabetic Retinopathy and Macrovascular Complication in Patients with Type 2 Diabetes / 대한내과학회지

BACKGROUND/AIMS: Type 2 diabetes with microvascular complications is often accompanied by macrovascular complications. However, the relationship between the two complications is unclear. In this study, we determined the relationship between diabetic retinopathy and morphological changes of the carotid artery. METHODS: We analyzed the presence of plaque and mean carotid intima-media thickness (CIMT) in patients with type 2 diabetes (n = 133) using high-resolution ultrasound. The presence and severity of retinopathy were graded according to fundus photographs. RESULTS: The mean CIMT of the diabetic retinopathy (DR) group (0.111 +/- 0.048 cm) was significantly greater than that of the nondiabetic retinopathy (No DR) group (0.074 +/- 0.039 cm, p = 0.007). An abnormal mean CIMT (> 0.08 cm) was more frequently observed in the DR group (76%) than that in the No DR group (23.1%; odds ratio, 10.609; 95% confidence interval, 3.072-36.639; adjusted by age, body mass index, hypertension, and diabetes duration). Although the mean CIMT in patients with plaque was significantly greater than that of patients without plaque, no significant difference was observed between the DR (36%, 17 patients) and NoDR (18.5%, 20 patients) groups in the presence of plaque. CONCLUSIONS: Diabetic retinopathy was associated with an increased CIMT but not with atherosclerotic plaques. However, the increases in IMT were associated with the presence of plaques, which predispose patients to cardiovascular disease. These results imply that the microvascular complications of diabetes have indirect relationships with the cardiovascular complications of diabetes.

A Case of Demyelinating Peripheral Neuropathy Associated with Hashimoto's Thyroiditis

Peripheral neuropathy is somewhat common in hypothyroidism. But, demyelinating peripheral neuropathy in Hashimoto's thyroiditis is extremely rare. The pathophysiology of demyelinating peripheral neuropathy associated with Hashimoto's thyroiditis is unclear and complex and various mechanisms including the cell mediated and antibody mediated responses may be operative. We report a 68-year-old woman who presented with paresthesia and gait disturbance. She was diagnosed with hypothyroidism 7 years prior and has been on thyroid hormone. Serum antithyroglobulin antibody was significantly elevated. Nerve conduction studies revealed sensory-motor demyelinating polyneuropathy with prolonged distal latencies and reduced conduction velocities. She was under the suspicion of the lymphoma of thyroid. Surgery was performed which turned up to be Hashimoto's thyroiditis. With the impression of rare demyelinating peripheral neuropathy associated with Hashimoto's thyroiditis after other causes were excluded, she was treated with steroid which ameliorated rapidly her neurological symptoms.

Osteoporosis and Decrease in Bone Mineral Density Have associated with the Reduced Quality Of Life / 대한골다공증학회지

OBJECTIVES: There are lack of study for the association between osteoporosis and reduced quality of life in Korean. In this study, the association between osteoporosis and reduced quality of life were analyzed. METHODS: We used the data from the fourth Korea National Health and Nutrition Examination Survey (KNHNES), and 891 women were enrolled who were over the age of 50. Bone mineral density was measured by dual-energy X-ray absorptiometry. The quality of life were measured EuroQol-5 Dimension (EQ-5D). RESULTS: The quality of life of osteoporosis patients, were reduced in all dimensions of EQ-5D, except EuroQol;anxiety and depression. However, EuroQol; anxiety depression side (P=0.05) and VAS (P=0.039) of EQ-5D had significant difference among osteoporosis, osteopenia, and normal group even after adjusted with age, weight, waist circumference, and blood levels of vitamin D. In addition, bone density and EQ-5D utility values had positive association even after adjusted with age and weight, waist circumference, blood levels of vitamin D (R2=0.137, B=0.148, P=0.011). CONCLUSIONS: The elderly women with osteoporosis were significantly associated with decreased quality of life. Thus, the quality of life should be considered in treating of osteoporosis patients.

Changes of Central Obesity is the Major Determinant of Influences of Weight Reduction on Bone Mineral Density / 대한골다공증학회지

OBJECTIVES: Obesity and osteoporosis have been increasing for decades but their relationship to bone mineral density (BMD) and fat mass has not been defined. The aim of this study was to investigate how changes in body composition affect BMD after a weight reduction. MATERIALS AND METHODS: We reviewed 48 middle-aged obese women who had participated in our diet program and succeeded in reducing their weight. Body composition was measured by the dual-energy X-ray absorptiometry method, and metabolic syndrome was defined as described in the ATP-III guidelines. All differences between baseline and 12 weeks later were expressed as [{12th week data-baseline data}/baseline datax100]. RESULTS: The mean age of the participants was 38.29+/-10.89 years, and the mean follow-up time was 85 days. The mean body mass index was 31.50+/-5.19 kg/m2. Basal BMD decreased with age and increased with weight and appendicular lean mass. In a regression analysis, appendicular lean mass was positively correlated with leg BMD (R2=0.235, B=0.015, P<0.001) and age (B=-0.002, P=0.046), and appendicular lean mass (B=0.019, P=0.049) was the main determinant of total BMD (R2=0.272). After weight reduction, the total body BMD change ratio (R2=0.281) was negatively related to the change of fat mass, trunk fat mass (B=-0.042, P=0.087) and waist circumference (B=-0.108, P=0.014). CONCLUSIONS: Our findings suggest that BMD is determined by muscle mass, and that changes in central obesity may also affect BMD.

A case of diabetes mellitus associated with Klinefelter's syndrome / 대한내과학회지

An increased frequency of diabetes or impaired glucose tolerance in Klinefelter's syndrome has been previously reported. Insulin resistance is considered to be the cause of this phenomenon in Klinefelter's syndrome, which is associated with low serum SHBG and sex hormone deficiency. Sex hormone deficiencies also result in dyslipidemia and metabolic syndrome. The interrelationship between diabetes, metabolic syndrome, and androgen deficiency is complex. Here we report a case of an 18-year-old man first diagnosed with diabetes mellitus 3 years ago. Upon physical examination the patient showed characteristic phenotypes compatible with primary hypogonadism. Subsequently, tests aimed at determining the cause of hypogonadism, including a chromosomal analysis, suggested Klinefelter's syndrome. The patient's HOMA-IR score was compatible with insulin resistance. Therefore, when diabetes mellitus develops at a young age with characteristic phenotypes, a careful history and physical examination may be needed to determine whether the patient might have primary hypogonadism caused by Klinefelter's syndrome.

A Case of Pseudohypoparathyroidism with Graves' Disease

Pseudohypoparathyroidism is a rare disease that is characterized by target cell resistance to the effects of parathyroid hormone and this disease is classified into various types depending on the phenotypic and biochemical findings. The patients with pseudohypoparathyroidism present with the clinical and biochemical features of hypoparathyroidism, but they have an increased serum level of parathyroid hormone. We experienced a case of pseudohypoparathyroidism in a 24 years old woman who had Graves' disease at that time. She had hypocalcemia, hyperphosphatemia, an elevated serum parathyroid hormone level and a normal urinary basal cyclic AMP(adenosine monophosphate) level. She also had a normal phenotypic appearance. Therefore, she was classified as suffering with pseudohypoparathyroidism type II. The clinical and laboratory abnormalities were improved by calcium supplementation in addition to vitamin D. To the best of our knowledge, this is the first case of pseudohypoparathyroidism combined with Graves' disease in Korea.

Effects of seaweed supplementation on blood glucose concentration, lipid profile, and antioxidant enzyme activities in patients with type 2 diabetes mellitus

The present study was carried out to evaluate the physiological effects of seaweed supplementation on blood glucose levels, lipid profile, and antioxidant enzyme activities in subjects with type 2 diabetes mellitus. Subjects were randomized into either a control group or a seaweed supplementation group. Pills with equal parts of dry powdered sea tangle and sea mustard were provided to the seaweed supplementation group three times a day for 4 weeks. Total daily consumption of seaweed was 48 g. We found that total dietary fiber intake was 2.5 times higher in subjects receiving seaweed supplementation than in the control group. Accordingly, fasting blood glucose levels (p<0.01) and 2-hour postprandial blood glucose measurements (p<0.05) were decreased significantly in those ingesting seaweed. Furthermore, the serum concentrations of triglycerides were decreased and high-density lipoprotein cholesterol was increased significantly in seaweed supplement group (p<0.05). However, the concentrations of total cholesterol and low-density lipoprotein cholesterol were not affected by seaweed supplementation. The level of thiobarbituric acid reactive substances in erythrocytes was significantly lower with seaweed supplementation compared to controls (p<0.05). Catalase and glutathione peroxidase activities with seaweed supplementation were higher than the controls (p<0.05), but superoxide dismutase activity was not affected. We, therefore, conclude that ingestion of seaweed influences glycemic control, lowers blood lipids, and increases antioxidant enzyme activities.

Clinical Manifestation and Differential Diagnosis of Thyroid Follicular Neoplasm / 대한이비인후과학회지

BACKGROUND AND OBJECTIVES: A preoperative differential diagnosis between follicular adenoma and follicular carcinoma of thyroid is very difficult, and the standard basis for distinction is the presence of capsular and/or vascular invasion. In this study, we analyzed the findings of preoperative tests and clinical features to facilitate the differential diagnosis and treatment of the follicular neoplasm. SUBJECTS AND METHOD: A retrospective review of medical records was carried out on 104 patients who had undergone thyroid surgery and had been diagnosed with thyroid follicular adenoma or carcinoma from 1995 through 2004. The final pathologic diagnosis was compared to the various clinical data including the result of fine needle aspiration cytology (FNAC) and ultrasonographic findings. RESULTS: Of total 104 cases, 82 were follicular adenoma and 22 were follicular carcinoma. The incidence of carcinoma was significantly higher in male than in female. The result of FNAC were divided into 6 cytodiagnostic groups, namely, inadequate, colloid nodule without atypia, colloid nodule with atypia, follicular neoplasm without atypia, follicular neoplasm with atypia, or highly suspicious malignancy. The incidence of carcinoma was significantly higher in the groups with atypia such as colloid nodule with atypia, follicular neoplasm with atypia, and highly suspicious malignancy than in the groups without atypia. The incidence of follicular carcinoma was significantly higher in ill-defined marginal cases. Calcification on ultrasonography also indicated the possibility of malignancy. CONCLUSION: The incidence of follicular carcinoma was significantly high in male patients, atypia in FNAC, and ill-defined margin and calcification on ultrasonography.

Effects of Mushroom Supplementation on Blood Glucose Concentration, Lipid Profile, and Antioxidant Enzyme Activities in Patients with Type 2 Diabetes Mellitus

The present study was carried out to evaluate the physiological effects of mushroom supplementation on blood glucose levels, lipid profile, and antioxidant enzyme activities in subjects with type 2 diabetes mellitus. Subjects were randomized into either a control group or mushroom supplementation group. Mushroom supplementation was provided 3 times a day for 4 weeks. We found that total dietary fiber intake was about 2.5 times higher (30.3 g vs. 12.3 g) in subjects receiving mushroom supplementation than in the control group. Two groups maintained the same food intake and amount of activity, exercise during the supplementation. We observed no difference in age, height, weight, BMI (body mass index), blood pressure between the groups. Nutrient intake did not differ appreciably between the two groups, except for fiber intake, during the supplementation. Fasting blood glucose levels and 2-hour postprandial blood glucose levels were significantly lower in those ingesting mushroom than in controls. Furthermore, the concentrations of low-density lipoprotein cholesterol were decreased significantly in the mushroom supplementation group. Small changes were observed in the concentration of total cholesterol, triglyceride, high-density lipoprotein cholesterol of those supplemented with mushroom, but these changes were not statistically significant. Activities of superoxide dismutase and catalase with mushroom supplementation were higher than in controls, but and glutathione peroxidase activity was not affected. The levels of thiobarbituric acid reactive substance of mushroom group were lower than control group, but were not siginificant. We conclude that addition of mushroom influences glycemic control and may be effective in lowering blood lipids and improving antioxidant enzyme activities. Accordingly, such effects may reduce risk factors for cardiovascular disease in patients with type 2 diabetes. However, to confirm these effects and to make dietary recommendations for patients with type 2 diabetes, further studies are necessary.

The relation of the testosterone level with metabolic syndrome and coronary artery disease in Korean middle-aged and elderly men / 대한내과학회지

BACKGROUND: Abdominal obesity is an essential component of metabolic syndrome and it causes insulin resistance. In contrast to women, the serum testosterone level has an inverse relationship with the visceral fat mass in men. Therefore, we investigated the relation of the serum testosterone concentration with metabolic syndrome and coronary artery disease in Korean middle-aged and elderly men. METHODS: 211 male subjects who were admitted to the cardiology department due to chest pain at Hanyang University Hospital from January to December, 2005 (mean age: 59.1+/-10.7 yrs) were enrolled in this study. All the blood samplings for laboratory tests, including the testosterone and estradiol tests, were done between 6 AM to 8 AM. Coronary artery disease was defined when there was more than 50% narrowing of the vascular lumen on the coronary angiography. Metabolic syndrome was defined according to the NCEP-ATP III guidelines. RESULTS: Among the other cardiovascular risk factors, metabolic syndrome was the most important contributor to coronary artery disease (adjusted OR=4.32, 95% CI: 1.96-9.52). Even after adjustment for age, BMI, smoking, alcohol consumption and hypertension, lower testosterone was associated with a higher fasting glucose level (p<0.01) and higher insulin resistance (p<0.05). Each SD (1.88 ng/mL) increase in the total testosterone was associated with a 51% reduced risk of having metabolic syndrome (OR=0.49; 95% CI, 0.36-0.68). Although men with coronary artery disease tended to have lower testosterone levels, there was no statistical significance. CONCLUSIONS: Lower testosterone levels might have a causative role in the development of metabolic syndrome and possibly coronary artery disease through the induction of insulin resistance.

A Case of Thyrotoxicosis Presented as Rhabdomyolysis / 대한내분비학회지

There have been a few reports on rhabdomyolysis caused by thyroid storm, but no cases of thyrotoxicosis related rhabdomyolysis have been reported until now. Here, a rare case of rhabdomyolysis, accompanied by thyrotoxicosis, is reported. A 21-year-old man was admitted to our hospital with severe pain and weakness in both legs. The initial laboratory findings revealed a high muscle enzyme level and severe hypokalemia. In evaluation of the rhabdomyolysis, the thyroid function test was compatible with that of Graves' disease, with the rhabdomyolysis subsequently diagnosed, presenting as thyrotoxicosis. The possible mechanisms for this complaint were hypokalemia-induced muscle ischemia, a thyrotoxicosis-induced excessive hypermetabolic state and pressure-induced muscle ischemia. Therefore, the work up for the cause of rhabdomyolysis should include thyrotoxicosis. The management of rhabdomyolysis is hydration, prevention of acute renal failure, correction of aggravating factors and treatment of the underlying cause, for example, thyrotoxicosis.

A case of hyperthyroidism with complete atrioventricular block / 대한내과학회지

The importance of cardiovascular system involvement in hyperthyroidism has been recognized for many years. Many electrocardiographic abnormalities have been described in hyperthyroidism, including sinus tachycardia, atrial fibrillation, and atrial or ventricular extrasystoles and the increase in resting heart rate are characteristics of hyperthyroidism. In the middle aged or elderly patients, often with mild but prolonged elevation of plasma thyroid hormone, symptoms and sign of heart failure and complicating atrial fibrillation may eliminate the classical clinical feature and mask the more classical endocrine manifestation of the disease. Though rare in hyperthyroidism, the development of heart block is important to recognize in clinical practice. The mechanism of variable delayed conduction (from 1st degree to complete heart block) in hyperthyroidism is not well documented until now. We experienced 67-year-old female patient who complained of loss of body weight. After work-up with thyroid function test and electrocardiogrpahy, we found that she had hyperthyroidism with complete atrioventricular block. We started antithyroid drug and continued to monitor electrocardiophy. We are going to give the radioactive iodine theraphy and in the case of symptomatic atrioventricular block, we will make a insertion of pacemaker.