A Case of Different Organ Responses to Immunosuppressive Therapy In a Microscopic Polyangiitis Patient with Interstitial Lung Disease / 대한내과학회지

Microscopic polyangiitis (MPA) is an idiopathic autoimmune disease characterized by systemic vasculitis associated with antineutrophil cytoplasmic autoantibodies. Interstitial lung disease is a less recognized manifestation of MPA and has a poor prognosis. A 61-year-old man presented with persistent cough, sputum and dyspnea. Laboratory examination revealed microscopic hematuria and renal insufficiency. Perinuclear anti-neutrophil cytoplasmic autoantibodies were positive according to serological testing. Computed tomography scans showed bibasilar reticulation and honeycombing in a peripheral distribution. Therefore, renal biopsy was performed, and MPA was diagnosed. After treating with corticosteroids and immunosuppressive agents, the patient had a complete renal response but progressive interstitial lung disease. We report a case of MPA presenting with interstitial lung disease in which the patient experienced different responses in each organ.

Typhoid Fever Complicated by Intussusception, Splenic Infarction, and Hepatitis

Salmonella typhi infections usually manifest with high fever and gastrointestinal symptoms, however, occurrence of severe complications in other organs, such as pneumonitis, bronchitis, hepatitis, nephritis, encephalitis, and osteomyelitis, is possible. Although common surgical complications include ileal perforation and gastrointestinal haemorrhage, few cases of intussusception have been reported. Splenic infarction is another uncommon complication. In this report, we present a case of typhoid fever complicated with simultaneous small bowel intussusception and splenic infarction. A 27-year-old male patient with no previous history of interest underwent examination for fever, acute abdominal pain, and watery diarrhea of seven days duration. Findings on the initial examination indicated fever of 39.1degrees C, a distended abdomen with direct and rebound tenderness of diffuse localization, and rigidity. Abdominal computed tomography showed hepatomegaly, multiple lymphadenopathies, multiple segmental splenic infarctions, and small bowel ileus with intussusception, however, findings from the small bowel enema study showed spontaneous resolution of the intussusception. Despite antibiotic therapy, abdominal symptoms continued, therefore, the patient underwent exploratory laparotomy with suspicion of intestinal perforation. Surgical findings included multiple enlarged lymphadenopathies and coarse appearance of the liver, but no perforation was found. Results of the Widal test showed positivity for flagellar (H), somatic (O) and A antigens (1:640 dilutions each). Blood cultures showed Salmonella typhi. lymph nodes and biopsy showed mesenteric lymphadenitis, with enlarged lymph nodes due to distension of the sinusoids by macrophages, which showed erythrophagocytosis and tingible bodies. In addition, liver biopsy showed a granulomatous aggregate comprised of macrophages with an epithelioid configuration. After intravenous administration of antibiotics, the patient showed progressive improvement and was discharged for outpatient department follow up.

A Patient with Distinct Evidences of Spontaneous Regression and Recurrence of Gastric Cancer for 13 Years

Spontaneous regression (SR) of malignancy is a rare phenomenon, especially in patients with gastric cancer. A 77-year-old male, who was already diagnosed with gastric adenocarcinoma by endoscopic biopsy from a private clinic, was referred to our hospital. Despite our strong recommendation, the patient refused surgical therapy. A follow-up endoscopy was performed 3 months later, which revealed that the ulcer had changed into a white scar. Endoscopic biopsy revealed only chronic inflammation. Two and 6 years later, cancer recurred, and SR was confirmed both times, histologically, at the gastric body. The patient is still alive without any gastrointestinal symptoms after 13 years of follow-up. The cause of SR is yet uncertain and there are only a few suggestions of scientific mechanisms. We, herein, report this very rare case of repeated recurrence and SR of gastric cancer without clear cause.

Transformation of CD5-Negative Follicular Lymphoma into CD5-Positive Diffuse Large B-Cell Lymphoma: A Case Report / 대한내과학회지

Diffuse large B-cell lymphoma (DLBCL) is the most frequent subtype of aggressive lymphomas. Approximately 10% of DLBCL cases express CD5 as a surface antigen. CD5-positive DLBCL can occur as the de novo or secondary type. De novo CD5-positive DLBCL arises without previous lymphoproliferative disease, and secondary CD5-positive DLBCL may or may not manifest as Richter syndrome. The transformation of follicular lymphoma (FL) into DLBCL occurs in approximately one-third of all cases. The transformation of CD5-negative low-grade B-cell lymphoma to CD5-positive DLBCL is extremely rare. We report the clinical features of a rare case that presented with a transformation from CD5-negative FL to CD5-positive DLBL over 11 years. This is the second such case published in the English literature.

A Case of Diabetic Ketoacidosis Precipitated by Klebsiella Liver Abscess and Brain Abscess / 대한내과학회지

Diabetes mellitus is a known risk factor for Klebsiella pneumoniae liver abscess, and may be associated with metastatic complications. We report a case of diabetic ketoacidosis (DKA) precipitated by a K. pneumoniae liver abscess and followed by a brain abscess. A 31-year-old man with uncontrolled type 2 diabetes was admitted for DKA. Abdominal and pelvic computed tomography scans showed multiple abscesses in the lung, liver, both kidneys, and prostate gland. The blood culture yielded K. pneumoniae. The patient's condition improved following antibiotic and insulin therapy, and he was discharged. However, he was rehospitalized 10 days after discharge due to a generalized tonic-clonic seizure. Brain magnetic resonance imaging revealed a brain abscess in the right basal ganglia. The patient was given an intravenous injection of antibiotics (vancomycin and carbapenem), and he recovered well with no neurological sequelae.

A Case of Clostridium bifermentans Bacteremia in a Patient with Myelodysplastic Syndrome / 감염과화학요법

Cases of anaerobic bacteremia are rare, and the clinical impact of clostridial bacteremia remains to be clarified. Previous clinical reports have suggested that C. bifermentans is less virulent than other Clostridia species. This microorganism has occasionally been reported to cause septic arthritis, necrotizing pneumonia with empyema, brain abscesses, endocarditis, and metastatic osteomyelitis. Herein, we report on a case of C. bifermentans bacteremia in a patient with myelodysplastic syndrome in South Korea.

Agomelatine: Antidepressant with a New Mechanism of Action / 대한정신약물학회지

Currently available pharmacotherapies for depression still have a limited antidepressant efficacy with a delayed onset of several weeks, and still cause side effects. These unmet needs represent important reasons to continue to search for novel treatment options. A disorganization of circadian rhythms has been suggested to play an important role in the pathophysiology of major depression. Agomelatine is a new agent with a unique pharmacological profile. Agomelatine is both an agonist of melatonergic MT(1) and MT(2) receptors and a serotonergic 5-HT(2C) receptor antagonist. Many clinical trials have demonstrated the superior efficacy of agomelatine in comparison with placebo in the treatment major depressive disorder at the standard dose of 25 mg/day, with the possibility of increasing doses to 50 mg/day in those patients with insufficient improvement. Agomelatine was even effective in severely depressed patients. The safety and tolerability of agomelatine was comparable to placebo. It does not induce the side effects including serotonin syndrome and sexual dysfunction or discontinuation syndrome typical to other therapies, such as selective serotonin reuptake inhibitors. These properties give agomelatine a definite clinical advantage in the treatment of depression.

Factors Associated With the Response to Fluoxetine Treatment in Child and Adolescent Patients with Major Depressive Disorder; A Naturalistic Study / 대한정신약물학회지

OBJECTIVE: We evaluated the overall efficacy of fluoxetine and explored factors associated with the response to fluoxetine treatment in child and adolescent outpatients with major depression. METHODS: Child and adolescent outpatients with major depressive disorder who had been treated with fluoxetine for at least eight weeks were selected for a retrospective study. The medical records of the subjects (N=82) were reviewed to determine the details of clinical variables and the efficacy and pharmacological variables of fluoxetine. At eight weeks, Clinical Global Impression (CGI) scores were used to divide the subjects into two groups, i.e., clinical responders and non-responders, and the two groups were compared. RESULTS: Of the 82 patients, 64% (N=53) responded to fluoxetine treatment. Responders tended to be younger during the treatment period and tended to have had a shorter duration of depressive episodes prior to starting treatment, a lower family loading for depressive illness, and less difficulty in school than non-responders. Other variables did not differ significantly between responders and non-responders. CONCLUSION: Fluoxetine is effective for the treatment of depressed children and adolescents. Younger age, shorter duration of depressive episodes prior to starting treatment, lower family loading for depressive illness, and less difficulty in school were good predictors of the response to fluoxetine treatment.

Effect of Repetitive Transcranial Magnetic Stimulation in Drug Resistant Depressed Patients / 핵의학분자영상

PURPOSE: Repetitive transcranial magnetic stimulation (rTMS) has recently been clinically applied in the treatment of drug resistant depressed patients. There are mixed findings about the efficacy of rTMS on depression. Furthermore, the influence of rTMS on the physiology of the brain is not clear. We prospectively evaluated changes of regional cerebral blood flow (rCBF) between pre- and post-rTMS treatment in patients with drug resistant depression. MATERIALS AND METHODS: Twelve patients with drug-resistant depression (7 male, 5 female; age range: 19~52 years; mean age: 29.3+/-9.3 years) were given rTMS on right prefrontal lobe with low frequency (1 Hz) and on left prefrontal lobe with high frequency (20 Hz), with 20-minute-duration each day for 3 weeks. Tc-99m ECD brain perfusion SPECT was obtained before and after rTMS treatment. The changes of cerebral perfusion were analyzed using statistical parametric mapping (SPM; t=3.14, uncorrected p<0.01, voxel=100). RESULTS: Following areas showed significant increase in rCBF after 3 weeks rTMS treatment: the cingulate gyrus, fusiform gyrus of right temporal lobe, precuneus, and left lateral globus pallidus. Significant decrement was noted in: the precental and middle frontal gyrus of right frontal lobe, and fusiform gyrus of left occipital lobe. CONCLUSION: Low-frequency rTMS on the right prefrontal cortex and high-frequency rTMS on the left prefrontal cortex for 3 weeks as an add-on regimen have increased and decreased rCBF in the specific brain regions in drug-resistant depressed patients. Further analyses correlating clinical characteristics and treatment paradigm with functional imaging data may be helpful in clarifying the pathophysiology of drug-resistant depressed patients.

Outbreak of Scabies at Geriatric Long-Term Care Facilities in Korea / 한국역학회지

OBJECTIVES: To investigate an outbreak of scabies that occurred in geriatricfacilities located in Kyounggi-province, Korea, between September 2004 and September 2005. METHODS: We carried out an epidemiologic investigation on the scabies outbreak. All workers except two were interviewed and the charts of the patients were reviewed. RESULTS: Among workers, the attack rate was 58.6% (17/29). The rate was 86.0%(37/43) in patients. Secondary cases also occurred among the family members of workers, with a secondary attack rate of 15.8%. The 95% confidence interval was 6%~31.3%. The transmission of scabies began from one index case who had scabies and moved from another facility. She was hospitalized on the 4th floor of this facilitywhere dependent patients resided. After the activities (picnic and yard sale) in May 2005, and the ward rotation of care givers between the 3rd and 4th floor in July 2005, the incidence of scabies increased. The last cases occurred in Sep. 2005. CONCLUSIONS: This outbreak investigation has importance because it is the first report of ascabies outbreak in geriatric long-term care facilities in Korea. Recently, the reports on a scabies epidemic are increasing with the augmentation of geriatric long-term care facilities. It is important to educate and inform workers and staff in long-term care facilities about scabies and other contagious skin diseases. More facilities for senility and dementia will be opened and we need to lookinto contagious diseases in long-term care facilities.