Diagnostic Approach to a Patient with a Pleural Effusion Including Ultrasound-guided Paracentesis Performed by a Medical Resident / 결핵및호흡기질환

BACKGROUND: A patient with a pleural effusion that is difficult to safely drain by a "blind" thoracentesis procedure is generally referred to a radiologist for ultrasound-guided thoracentesis. But such a referral increases the cost and the patient's inconvenience, and it causes delay in the diagnostic procedures. If ultrasound-guided thoracentesis is performed as a bedside procedure by a medical resident, then this will reduce the previously mentioned problems. So these patients with pleural effusions were treated by medical residents at our medical center, and the procedures included bedside ultrasound-guided thoracenteses. METHODS: We studied 89 cases of pleural effusions from March 2003 to June 2005. A "blind" thoracentesis was performed if the amount of pleural effusion was moderate or large. Bedside ultrasound-guided thoracentesis was performed for small or loculated effusions or for the cases that failed with performing a "blind" thoracentesis. RESULTS: "Blind" thoracenteses were performed in 79 cases that had a moderate or large amount of uncomplicated pleural effusions and the success rate was 93.7% (74/79 cases). Ultrasound-guided thoracentesis by the medical residents was performed in 15 cases and the success rate was 66.7% (10/15 cases). The 5 failedcases included all 3 cases with loculated effusions and 2 cases with a small amount of pleural effusion. All the failed cases were referred to one radiologist and they were then successfully treated. If we exclude the 3 cases with loculated pleural effusions, the success rate of ultrasound-guided thoracentesis by the medical residents increased up to 83% (10/12 cases). Two cases of complications (1 pneumothorax, 1 hydrohemothorax) occurred during ultrasound-guided thoracentesis. CONCLUSION: Ultrasound-guided thoracentesis performed as a bedside procedure by a medical resident may be relatively effective and safe. If a patient has a loculated effusion, then it would be better to first refer the patient to a radiologist.

A case of chronic neutrophilic leukemia / 대한내과학회지

Chronic neutrophilic leukemia (CNL) is a rare myeloproliferative disorder characterized by clonal proliferation of mature neutrophils, hepatosplenomegaly, elevated leukocyte alkaline phosphatase score (ALP score) and a negative Philadelphia chromosome. To date, approximately 150 cases have been reported in the literature, including some cases presenting with a 'leukemic' state reflected by a neutrophilic reaction. The term 'true' CNL, recently introduced by Reilly, highlights the need for more experience with CNL cases to improve the diagnostic criteria. In Korea, about 10 cases have been reported in the literature and some of those cases did not meet the WHO diagnostic criteria for CNL. We present a typical case of CNL in a 66-year-old man who complained of general weakness and weight loss. On admission, the white blood cell count from the peripheral blood was 175,600/L with 80% segmented neutrophils. The cytogenic study was negative for the Philadelphia chromosome and had a normal karyotype.