A case report on the role of endoscopic retrograde cholangiopancreatography in the diagnosis of hemosuccus pancreaticus.

RATIONALE: Hemosuccus pancreaticus (HP) is a rare cause of gastrointestinal bleeding that sometimes leads to life-threatening conditions. However, the diagnosis of HP is often delayed due to its rarity and intermittent signs of bleeding, making it challenging to determine the source of bleeding in some patients. PATIENT CONCERNS: An 83-years-old man was transferred to our hospital for evaluation of the source of intermittent upper gastrointestinal bleeding involving melena and worsening anemia. DIAGNOSIS: HP was diagnosed via endoscopic retrograde cholangiopancreatography (ERCP) and sequential angiography using a multidisciplinary approach. INTERVENTIONS: Initial upper and lower gastrointestinal endoscopies did not reveal any source of bleeding. Emergency upper endoscopy performed when the patient had hematochezia and hypotension confirmed a spurt of bleeding from the major duodenal papilla. However, contrast-enhanced computed tomography and angiography could not identify the source of the bleeding from the major duodenal papilla. ERCP for inducing bleeding from the source and indicating the bleeding point was performed according to the decision of the multidisciplinary team. Immediately thereafter, sequential angiography was performed and HP, due to the rupture of a pseudoaneurysm of the splenic artery, was diagnosed. As a result, surgical resection of the pancreas could be avoided by accurately embolizing the bleeding focus of HP using a multidisciplinary team approach. OUTCOMES: The patient was discharged in a hemodynamically stable condition. There was no further gastrointestinal bleeding or procedure-related complication until 6 months after discharge. LESSONS: HP should be considered by endoscopists during the differential diagnosis of intermittent upper gastrointestinal bleeding in patients with a history of pancreatitis. A multidisciplinary team approach is an effective method to determine the source or location of bleeding, which may reduce mortality and morbidity by avoiding additional pancreatectomies.

Percutaneous endoscopic necrosectomy in a patient with emphysematous pancreatitis: A case report.

RATIONALE: Emphysematous pancreatitis, a rare complication of acute necrotizing pancreatitis with a high mortality rate, is associated with gas-forming bacteria. When using the step-up approach for treating emphysematous pancreatitis, it is preferable to delay drainage interventions for 4 weeks. However, percutaneous drainage may be necessary, even in the early phase of acute pancreatitis, for a patient whose sepsis deteriorates despite optimal medical management. Percutaneous drainage can then be followed by endoscopic necrosectomy through the percutaneous tract. PATIENT CONCERNS: A 52-year-old man was transferred to our hospital for treatment of sepsis and multiorgan failure associated with emphysematous pancreatitis. DIAGNOSIS: An abdominal computed tomography scan had shown pancreatic and peripancreatic necrosis, along with extensive gas bubbles. INTERVENTIONS: Despite optimal medical management, the patient's condition continued to deteriorate, and it became necessary to insert 2 percutaneous catheter drainages (PCDs), even though the patient was still in the early phase of pancreatitis. Each PCD was upsized and irrigated with sterile saline by an interventional radiologist twice a week. The infected necrosis around the tail of the pancreas was completely resolved after PCD. However, PCD through the transperitoneal route did not resolve necrosis around the pancreatic head. Following the PCDs, percutaneous pancreatic necrosectomy using an ultra-slim upper endoscope was performed, after which the patient recovered quickly and was discharged. OUTCOMES: Follow-up computed tomography was performed 12 weeks after the patient was discharged, and it showed complete resolution of the walled-off necrosis. The patient's condition improved without any fluid collection or complications. LESSONS: PCD can be used in the early phase of emphysematous pancreatitis for patients who continue to deteriorate due to sepsis. This can easily be followed, if necessary, by percutaneous pancreatic necrosectomy using an ultra-slim endoscope.

A case of ascending colon variceal bleeding treated with venous coil embolization.

A 38-year-old female with a history of alcoholic liver cirrhosis visited our hospital with a massive hematochezia. An esophagogastroduodenoscopy did not demonstrate any bleeding source, and a colonoscopy showed a massive hemorrhage in the ascending colon but without an obvious focus. The source of the bleeding could not be found with a mesenteric artery angiography. We performed an enhanced abdominal computed tomography, which revealed a distal ascending colonic varix, and assumed that the varix was the source of the bleeding. We performed a venous coil embolization and histoacryl injection to obliterate the colon varix. The intervention appeared to be successful because the vital signs and hemoglobin laboratory data remained stable and because the hematochezia was no longer observed. We report here on a rare case of colonic variceal bleeding that was treated with venous coil embolization.

Post-traumatic pseudoaneurysm of the medial plantar artery combined with tarsal tunnel syndrome: two case reports.

Pseudoaneurysms in the foot are more often reported in the lateral plantar artery than the medial plantar artery, most likely because of its more superficial location. There are no reports of pseudoaneurysm of the medial plantar artery after trauma. We present two cases of pseudoaneurysm of the medial plantar artery after blunt foot trauma and foot laceration. This pseudoaneurysm compressed a posterior tibial nerve, resulting in tarsal tunnel syndrome. The patients were treated successfully using transcatheter embolization without the need for surgical intervention. The tarsal tunnel syndrome also subsided. Here, the authors report these cases and provide a review of literature.

Pandemic 2009 H1N1 virus infection in children and adults: A cohort study at a single hospital throughout the epidemic.

BACKGROUND: In 2009, there was an influenza pandemic in South Korea. The aim of this study was to evaluate the epidemiological, clinical and laboratory characteristics of this infection in children and adults. METHODS: We evaluated the epidemiologic characteristics of patients infected with the 2009 H1N1 influenza A virus (4,463 patients, age range from 2 mo to 86 y), and the clinical and laboratory findings of 373 inpatients (80/217 children, ≤ 15 y, had pneumonia and 36/156 adults, > 16 y, had pneumonia) in a single hospital during the epidemic. RESULTS: The majority of infected patients (94%) were less than 40 y, and greater than 90% of cases occurred during a two-month period. The rates of admission and pneumonia were 8.4% (373/4,463) and 2.5% (116/4,463), respectively. The rates of admission and pneumonia, total duration of fever, the frequency of underlying diseases, and the values of C-reactive protein and erythrocyte sedimentation rate tended to increase as age increased; highest rates were found in the ≥ 65 y group. Pneumonia was founded more boys than girls in children, but more female than male in adults. The adult patients with pneumonia had higher leukocyte counts with lower lymphocyte differentials than the group without pneumonia, as shown in children group. CONCLUSION: Our results suggest that the immunologic reaction to viral insults may be associated with age, sex and underlying diseases, and that unknown herd immunity may affect populations. The patients with underlying diseases, especially in older patients may have immunologic insufficiency that is associated with immunologic consumption by the underlying diseases.

Acetazolamide-challenged perfusion magnetic resonance imaging for assessment of cerebrovascular reserve capacity in patients with symptomatic middle cerebral artery stenosis: comparison with technetium-99m-hexamethylpropyleneamine oxime single-photon emission computed tomography.

OBJECTIVES: Acetazolamide-challenged perfusion magnetic resonance imaging (MRI) has been shown as a method for assessment of cerebrovascular reserve (CVR) capacity in patients with atherosclerotic steno-occlusive disease of internal carotid artery. We have assessed the feasibility of the acetazolamide-challenged perfusion MRI for evaluating CVR in symptomatic patients with severe middle cerebral artery (MCA) stenosis (≥70%) by comparison with the acetazolamide-challenged technetium-99m-hexamethylpropyleneamine oxime (HMPAO) single-photon emission computed tomography (SPECT). METHODS: Seventeen prospectively enrolled patients with symptomatic unilateral MCA stenosis underwent technetium-99m-hexamethylpropyleneamine oxime SPECT and perfusion MRI without and with acetazolamide challenge, respectively. Acetazolamide-challenged SPECT and perfusion MRI were compared quantitatively by Region of interest (ROI) analysis. RESULTS: At all ROIs, there were no significant differences in percent change between SPECT and perfusion MRI. Patients with impaired CVR showed significant decreases in the percent changes of respective cerebral blood flow (P=.016) and respective cerebral blood volume (P=.029). CONCLUSION: Acetazolamide-challenged perfusion MRI is feasible for evaluating CVR in symptomatic patients with severe MCA stenosis quantitatively.

Epidemiological and clinical characteristics of childhood pandemic 2009 H1N1 virus infection: an observational cohort study.

BACKGROUND: There was a pandemic influenza around the world in 2009 including South Korea since last pandemic occurred four decades ago. We aimed to evaluate the epidemiological and clinical characteristics of this infection in childhood. METHODS: We evaluated the epidemiologic characteristics of all the subjects infected with the 2009 H1N1 influenza A virus (2,971 patients, ≤ 15 years of age), and the clinical and laboratory findings of the inpatients (217 patients, 80 had pneumonia) between 1 September 2009 and 31 January 2010 in a single hospital throughout the epidemic. RESULTS: The age distribution of all the subjects was relatively even. Over 90% of cases occurred during a two-month period. Two hundred and five patients (94.5%) received oseltamivir within 48 h of fever onset, and 97% of inpatients defervesced within 48 h of medication. The group with pneumonia included more males than females, and had higher leukocytes counts with lower lymphocyte differentials than the group without pneumonia. The white blood cell count and lymphocyte differential were associated with the severity of pneumonia. Corticosteroid treatment for severe pneumonia patients was highly effective in preventing disease progression. CONCLUSION: Children of all ages affected with even rates of infection, but males were predominant in pneumonia patients. Pneumonia patients showed lymphopenia and its severity was associated with the severity of illness. Our results suggest that the mechanism of lung injury in 2009 H1N1 virus infection may be associated with the host immune response.

Difference of clinical features in childhood Mycoplasma pneumoniae pneumonia.

BACKGROUND: M. pneumoniae pneumonia (MP) has been reported in 10-40% of community-acquired pneumonia cases. We aimed to evaluate the difference of clinical features in children with MP, according to their age and chest radiographic patterns. METHODS: The diagnosis of MP was made by examinations at both admission and discharge and by two serologic tests: the indirect microparticle agglutinin assay (>or=1:40) and the cold agglutinins titer (>or=1:32). A total of 191 children with MP were grouped by age: or=6 years of age (81 patients). They were also grouped by pneumonia pattern: bronchopneumonia group (96 patients) and segmental/lobar pneumonia group (95 patients). RESULTS: Eighty-six patients (45%) were seroconverters, and the others showed increased antibody titers during hospitalization. Among the three age groups, the oldest children showed the longest duration of fever, highest C-reactive protein (CRP) values, and the most severe pneumonia pattern. The patients with segmental/lobar pneumonia were older and had longer fever duration and lower white blood cell (WBC) and lymphocyte counts, compared with those with bronchopneumonia. The patient group with the most severe pulmonary lesions had the most prolonged fever, highest CRP, highest rate of seroconverters, and lowest lymphocyte counts. Thrombocytosis was observed in 8% of patients at admission, but in 33% of patients at discharge. CONCLUSIONS: In MP, older children had more prolonged fever and more severe pulmonary lesions. The severity of pulmonary lesions was associated with the absence of diagnostic IgM antibodies at presentation and lymphocyte count. Short-term paired IgM serologic test may be mandatory for early and definitive diagnosis of MP.

Massive empyema associated with transient hypogammaglobulinemia of infancy and IgA deficiency.

Transient hypogammaglobulinemia of infancy (THI) is originally defined as a physiological maturation defect of immunoglobulin G (IgG) production that occurs at 3-6 months of age and lasts until 18 to 36 months of age. We report here on a 22-month-old child with THI and IgA deficiency, who had massive pneumococcal empyema. Her depressed IgG level returned to normal within 6 months, but IgA level was still low at 6 yr of age. Although THI is an age-dependent and self-limiting disorder, severe infection that includes an atypical presentation of an infection may occur in some patients and this requires evaluation with immunologic study.

Meniscal hematoma of the knee joint: a case report.

We report here an unusual case of medial meniscal hematoma of the knee joint. A review of the literature has revealed only one case that was previously reported. The authors present the successful decompression of the posterior horn of a medial meniscal hematoma through the direct posterior-posterior triangulation arthroscopic visualization method. We present here the case report.