Analysis of predictors influencing indeterminate whole-blood interferon-gamma release assay results in patients with rheumatic diseases.

Triggers of indeterminate results from interferon-gamma release assays (IGRA) in patients with rheumatic diseases are still elusive. The aim of the present study was to describe predictors of indeterminate results from IGRA in the field of rheumatology. This cross-sectional study was retrospectively performed by using a database of patients with a request for QuantiFERON-TB Gold-In Tube test (QFT-GIT) for screening of latent tuberculosis infection. The study cohort included 631 patients with rheumatic diseases. All variables influencing indeterminate QFT-GIT results were investigated by logistic regression analysis. The overall frequency of indeterminate IGRA results was 6.8 % (43/631). Those with indeterminate results were more likely to be aged ≥70 years, female, visitors in winter, suffering from systemic lupus erythematosus (SLE), and using sulfasalazine or a tumor necrosis factor (TNF)-α inhibitor. In addition, a longer incubation time of >6 h increased the odds ratio of indeterminate IGRA results. In contrast, the automated ELISA processor, ankylosing spondylitis, and the use of a non-steroidal anti-inflammatory drug decreased the likelihood of indeterminate IGRA results. Lymphopenia, thrombocytopenia, anemia, and hypoalbuminemia were significantly associated with indeterminate IGRA results. Multivariate analysis revealed that SLE, use of sulfasalazine or a TNF-α inhibitor, and a manual ELISA system were significantly independent predictors of indeterminate IGRA results. The proportion of indeterminate results in patients with rheumatic diseases is not infrequent. Careful attention to the pre-analytical conditions should minimize the indeterminate results. Automation of the ELISA process seems to be a promising solution to decrease the rate of indeterminate response.

Higher Ratio of Serum Alpha-Fetoprotein Could Predict Outcomes in Patients with Hepatitis B Virus-Associated Hepatocellular Carcinoma and Normal Alanine Aminotransferase.

BACKGROUND: The role of serum alpha-fetoprotein (AFP) levels in the surveillance and diagnosis of hepatocellular carcinoma (HCC) is controversial. The aim of this study was to investigate the value of serially measured serum AFP levels in HCC progression or recurrence after initial treatment. METHODS: A total of 722 consecutive patients newly diagnosed with HCC and treated at the National Cancer Center, Korea, between January 2004 and December 2009 were enrolled. The AFP ratios between 4-8 weeks post-treatment and those at the time of HCC progression or recurrence were obtained. Multivariate logistic regression analysis was performed to correlate the post-treatment AFP ratios with the presence of HCC progression or recurrence. RESULTS: The etiology of HCC was related to chronic hepatitis B virus (HBV) infection in 562 patients (77.8%), chronic hepatitis C virus (HCV) infection in 74 (10.2%), and non-viral cause in 86 (11.9%). There was a significant decrease in serum AFP levels from the baseline to 4 to 8 weeks after treatment (median AFP, 319.6 ng/mL vs. 49.6 ng/mL; p< 0.001). Multivariate analysis showed that an AFP ratio > 1.0 was an independently associated with HCC progression or recurrence. Among the different causes of HCC analyzed, this association was significant only for HCC related to chronic hepatitis B (p< 0.001) and non-viral causes (p<0.05), and limited only to patients who had normal alanine aminotransferase (ALT) levels. CONCLUSION: Serial measurements of serum AFP ratios could be helpful in detecting progression or recurrence in treated patients with HBV-HCC and normal ALT.

Discrepancy between Clinical and Final Pathological Evaluation Findings in Early Gastric Cancer Patients Treated with Endoscopic Submucosal Dissection.

PURPOSE: Early gastric cancer cases that are estimated to meet indications for treatment before endoscopic submucosal resection are often revealed to be out-of-indication after the treatment. We investigated the short-term treatment outcomes in patients with early gastric cancer according to the pretreatment clinical endoscopic submucosal resection indications. MATERIALS AND METHODS: We retrospectively reviewed the medical records of patients with early gastric cancer that met the pretreatment endoscopic submucosal resection indications, from 2004 to 2011. Curative resection rate and proportion of out-of-indication cases were compared according to the pre-endoscopic submucosal resection indications. Pre-endoscopic submucosal resection factors associated with out-of-indication in the final pathological examination were analyzed. RESULTS: Of 756 cases, 660 had absolute and 96 had expanded pre-endoscopic submucosal resection indications. The curative resection rate was significantly lower in the patients with expanded indications (64.6%) than in those with absolute indications (81.7%; P<0.001). The cases with expanded indications (30.2%) were revealed to be out-of-indication more frequently than the cases with absolute indications (13.8%; P<0.001). Age of >65 years, tumor size of >2 cm, tumor location in the upper-third segment of the stomach, and undifferentiated histological type in pre-endoscopic submucosal resection evaluations were significant risk factors for out-of-indication after endoscopic submucosal resection. CONCLUSIONS: Non-curative resection due to out-of-indication occurred in approximately one-third of the early gastric cancer cases that clinically met the expanded indications before endoscopic submucosal resection. The possibility of additional surgery should be emphasized for patients with early gastric cancers that clinically meet the expanded indications.

A case of serum sickness-like reaction and anaphylaxis - induced simultaneously by rifampin.

Rifampin is commonly used as a first-line anti-tuberculosis drug, but it can induce a serum sickness-like reaction or anaphylaxis. However, it is possible for 1 drug antigen to induce 2 or more simultaneous immunologic reactions. Here, we report a case of a serum-sickness-like reaction and anaphylaxis induced concurrently by rifampin. A 25-year-old male presented with high fever and a maculopapular rash with vesicles on the hands, which developed 2 weeks following regular administration of anti-tuberculosis drugs for tuberculous meningitis, including rifampin. Elevated liver enzymes, peripheral neuropathy, and decreased serum C3 and C4 levels were found. Interestingly, these symptoms were accompanied by severe hypotension. A serum-sickness-like reaction was considered after excluding other potential causes for the fever. A drug provocation test showed that the fever developed after oral administration of rifampin, suggesting that rifampin was the cause of the allergic reaction. However, hypotension, epigastric discomfort, and diarrhea also accompanied these symptoms, indicating that IgE-mediated type I hypersensitivity could be part of the serum sickness-like reaction. An intradermal skin test clearly showed an immediate positive reaction to rifampin. This case was diagnosed as concurrent serum-sickness-like reaction and anaphylaxis induced by rifampin. One drug may therefore induce combined allergic reactions via 2 or more simultaneous hypersensitivity responses.

Hypoparathyroidism and subclinical hypothyroidism with secondary hemochromatosis.

Hemochromatosis is an inherited genetic disorder of iron metabolism which can also occur as a secondary result of iron-overload. It leads to organ damage such as cardiomyopathy, liver cirrhosis, hypogonadism, and diabetes. This paper discusses a case of secondary hemochromatosis associated with repeated transfusions, presenting as asymptomatic hypoparathyroidism and subclinical hypothyroidism with multiple organ involvement. The 29-year-old female, who had severe aplastic anemia, received multiple transfusions totaling approximately 1,400 units of red blood cells over 15 years. During her routine laboratory examination, hypocalcemia was detected with decreased intact parathyroid hormone and increased thyroid stimulating hormone. Serum ferritin, iron, and total iron binding capacity had increased to 27,583.03 ng/mL, 291 µg/dL, and 389 µg/dL, respectively. She had unusually bronze skin and computed tomography revealed iron deposition in the thyroid, liver, and heart. Multiorgan involvement as seen in this case is rare in hemochromatosis associated with secondary transfusions. To the best of the author's knowledge, this is the first case report in Korea of hypoparathyroidism and subclinical hypothyroidism due to iron deposition in the parathyroid and thyroid gland.

A case of diaphragmatic hernia induced by radiofrequency ablation for hepatocellular carcinoma.

Because of its safety and treatment effectiveness, the popularity of radiofrequency ablation (RFA) for the treatment of hepatocellular carcinoma (HCC) has gradually increased. However, some serious complications of RFA such as hepatic infarction, bowel perforation, and tumor seeding have been reported. Recently, we experienced a case of diaphragmatic hernia after RFA for HCC. A 61-year-old man with alcoholic cirrhosis was diagnosed with a 1.0 cm sized HCC in segment (S) 5 and a 1.3 cm sized HCC in S 8 of the liver. He was treated by transarterial chemoembolization and RFA. After RFA, an abdominal CT revealed a diaphragmatic defect with herniating mesentery. Twenty-two months after the RFA, the chest CT showed the diaphragmatic defect with herniating colon and mesentery. Because he had no symptoms, and surgical repair for the diaphragmatic hernia would be a high risk operation for him, we decided to treat the patient conservatively. For its great rarity, we report this case with a review of the literature.