Activation of the coagulation cascade in patients with scrub typhus.

This retrospective study aimed to evaluate the levels of coagulation factors and presence of disseminated intravascular coagulation (DIC) in patients with scrub typhus. We included patients confirmed to have scrub typhus at the Chosun University Hospital between September 2004 and December 2009. The DIC scores were evaluated in 365 patients and 36 healthy controls. The median concentrations of fibrinogen, d-dimer, and fibrin/fibrinogen degradation products (FDP) were compared between patients and healthy controls (p<0.001 for all tests). Patients with scrub typhus had longer prothrombin time and lower platelet counts than the controls. Major bleeding was observed in 18/365 patients with scrub typhus. Fifty-one (14.0%) patients presented with severe complications of scrub typhus. Overt DIC and thrombocytopenia (<100,000 platelets/mm3) were observed more frequently in patients with bleeding and severe illness. Furthermore, median platelet counts were low in both groups. Approximately 2.7% (n=10) and 16.4% (n=60) patients with scrub typhus had overt DIC, as defined by the International Society on Thrombosis and Hemostasis DIC score (DIC1) and the DIC-scoring template with a fibrinogen/C-reactive protein-ratio (DIC2), respectively. Three (16.7%) and 10 (55.6%) patients with bleeding had overt DIC, as defined by the DIC1 and DIC2, respectively. Seven (13.7%) and 26 (51%) patients with severe illness had overt DIC, as defined by DIC1 and DIC2, respectively. In conclusion, activation of the coagulation system is an important feature of scrub typhus and is correlated with severe disease, including bleeding. This is the first study to report a relationship between DIC and scrub typhus.

Reactivation of hepatitis B (reverse seroconversion) after melphalan/dexamethasone therapy for primary amyloidosis: a case report.

INTRODUCTION: Hepatitis B virus (HBV) reactivation (so-called reverse seroconversion) is a rare but known complication of hematopoietic stem cell transplantation, immunosuppressive therapy, or high-dose chemotherapy plus rituximab. This event is linked to a treatment-related fall in titers of antibodies to hepatitis B surface antigen (HBsAb) below the protective threshold level. CASE PRESENTATION: A 77-year-old Korean man diagnosed with primary amyloidosis was started on melphalan/dexamethasone combination therapy. During treatment, laboratory indices of hepatic function suddenly deteriorated, and he developed acute hepatitis through reverse HBV seroconversion, becoming positive for hepatitis B surface antigen (HBsAg) and negative for HBsAb. HBV DNA was also detectable in serum to a profound extent. Normal liver function was gradually restored during the course of antiviral therapy (entecavir). CONCLUSIONS: HBV reactivation may lead to fatal liver disease in a significant percentage of patients. As a result, physicians often screen for HBsAg and HBsAb prior to initiating chemotherapy, advising antiviral treatment in patients seropositive for HBsAg, even in the absence of hepatitis B e antigen. Here, a case of HBV reactivation is described, involving a patient given relatively low-dose chemotherapy (melphalan/dexamethasone) for primary amyloidosis.

Evaluation of risk factors in patients with vitamin K-dependent coagulopathy presumed to be caused by exposure to brodifacoum.

BACKGROUND/AIMS: Recently, many cases of vitamin K-dependent coagulopathy of unknown origin have been reported. Such patients lack any relevant family history and have no systemic disease, raising suspicion of superwarfarin intoxication. We evaluated individual risk factors causing coagulopathy and hemorrhagic symptoms in patients with suspected superwarfarin intoxication. In addition, we determined how to effectively treat vitamin K-dependent coagulopathy caused by suspected superwarfarin intoxication. METHODS: Seven patients with suspected superwarfarin intoxication who lacked any definitive history of rodenticide ingestion were included. Thirty-one patients initially diagnosed with rodenticide poisoning were also included. We performed a retrospective chart review of all subjects and examined clinical data including patient demographics and medical histories. RESULTS: Patients initially diagnosed with rodenticide poisoning were divided into two groups, one of which had a laboratory abnormality (prothrombin time [PT] > 13 seconds) and another group with PTs in the normal range. There was no significant difference between the two groups in any of age, gender, the extent of chronic alcohol consumption, the causative rodenticide, psychiatric problems, ingestion of drugs interacting with warfarin, the extent of intoxication, or the type of ingestion attempt. The albumin level of the former group was significantly lower than that of the latter group (p = 0.014). Furthermore, a significant difference between the two groups was evident in terms of simultaneous ingestion of rodenticide and alcohol (p = 0.023). CONCLUSIONS: Most patients with superwarfarin poisoning did not exhibit any complication. When such complications were evident, they were associated with serum albumin level and coingestion of rodenticide and alcohol.

Health-related quality of life among cancer survivors in Korea: the Korea National Health and Nutrition Examination Survey.

OBJECTIVE: The purpose of this study was to investigate the quality of life among cancer survivors compared with individuals without a history of cancer (noncancer controls) using the Korea National Health and Nutrition Examination Survey. METHODS: The study subjects were 783 adult cancer survivors and 36 456 noncancer controls who participated in the third, fourth and fifth Korea National Health and Nutrition Examination Survey. Demographic factors, health-related behavior, clinical characteristics and health-related quality of life were assessed with self-reported questionnaires. The EuroQoL-5Dimension was used to evaluate health-related quality of life. Descriptive statistics and multiple regression analysis were used to compare health-related quality of life between cancer survivors and noncancer controls. RESULTS: About 67% were women and the mean age of the cancer survivors was 60.9 ± 12.4 years. About 52% of survivors were diagnosed with cancer between 45 and 64 years, and more than half of cancer survivors were diagnosed 5 years or less before the interview. The pain/discomfort dimension was the highest reported problem: 43.6% for cancer survivors. The proportion of any reported problem was significantly higher among cancer survivors compared with noncancer controls in terms of mobility (adjusted odds ratio (aOR), 1.56, 95% confidence interval, 1.24-1.97), usual activities (aOR, 1.45, 95% confidence interval, 1.11-1.89), pain/discomfort (aOR, 1.26, 95% confidence interval, 1.04-1.52) and anxiety/depression (aOR, 1.61, 95% confidence interval, 1.29-2.01). CONCLUSIONS: Cancer survivors had a significantly lower quality of life compared with noncancer controls. The pain/discomfort dimension was the highest reported problem in cancer survivors.

Spontaneous tumor lysis syndrome with resolution of pancytopenia and disappearance of lymphadenopathy in a patient with peripheral T cell lymphoma unspecified.

Tumor lysis syndrome is a well-described, serious complication of chemotherapy administered to treat malignancies. However, a very rare event resulting in the spontaneous necrosis of a tumor prior to therapy can also occur, which is termed spontaneous tumor lysis syndrome (STLS). We present a case of a 27-year-old male who presented to the hospital with epistaxis, dyspnea, and cervical lymphadenopathy. Laboratory findings included progressive pancytopenia, hyperuricemia, and acute renal failure. Bone marrow biopsy showed a T cell lymphoid neoplasm that had entirely infiltrated the marrow stroma. The patient was diagnosed with STLS in the setting of a T cell lymphoma with bone marrow infiltration. The patient was immediately treated with a blood transfusion and hemodialysis. After this urgent treatment, the patient's pancytopenia resolved and the lymphadenopathy disappeared spontaneously. One month post-treatment, the patient's cervical lymphadenopathy recurred and peripheral T cell lymphoma, not otherwise specified, was confirmed. STLS has previously been reported, however, most known cases of STLS did not show a decreased tumor burden resulting from massive tumor cell death. We present a rare case of STLS with resolution of pancytopenia and disappearance of lymphadenopathy in a patient with peripheral T cell lymphoma not otherwise specified.

Colon perforation during sorafenib therapy for advanced hepatocelluar carcinoma. A case report.

There are no effective conventional systemic cytotoxic therapies for patients with unresectable or advanced hepatocellar carcinoma (HCC). Sorafenib, an oral multi-targeted tyrosine kinase inhibitor, was recently approved for the treatment of patients with HCC. Sorafenib is generally well tolerated and has an acceptable toxicity profile.Gastrointestinal perforation is a rare adverse event. We present a case of transverse colon perforation during sorafenib therapy for advanced HCC. A 68-year-old woman with advanced HCC was treated with sorafenib. Eight weeks later the patient presented with the sudden onset of sharp abdominal pain. Emergency surgery was performed for panperitonitis and a perforation involving the transverse colon.

Successful treatment of small-cell lung cancer with irinotecan in a hemodialysis patient with end-stage renal disease.

The prognosis of patients with end-stage renal disease has improved with advances in hemodialysis techniques. However, many patients who undergo hemodialysis suffer from various types of cancer. Limited data is available to guide clinical management of these patients who may have impaired renal function. Here, we report our experience with the use of irinotecan for the treatment of a hemodialysis patient with small-cell lung cancer and end-stage renal disease.

Lupus anticoagulant-hypoprothrombinemia in healthy adult.

The presence of lupus anticoagulant is associated with an elevated risk of venous and arterial thrombosis, and recurrent miscarriages as well. For some cases, this disease can present with bleeding as a consequence of lupus anticoagulant hypoprothrombinemia (LAHPS). LAHPS is a rare disease and it is reported to be most frequent in young females with/without systemic lupus erythematosus or in healthy children who are suffering with a viral infection. In such cases, steroid therapy is usually effective in normalizing the biological abnormalities and controlling the bleeding problems. A 34-year-old previously healthy man was admitted to our department because of his prolonged coagulation times; these abnormalities were discovered before performing orthopedic surgery. The prothrombin time (PT) was 15.2 sec, and the activated partial thromboplastin time (APTT) was 37.7 sec. A 1:1 dilution of patient plasma with normal plasma nearly corrected the PT, but this failed to correct the APTT. Evaluation of the clotting factors revealed decreased levels of factors II, V, VIII, IX and XI. The presence of LA was demonstrated by the dRVVT test, and the patient was diagnosed with LAHPS. He was successfully treated with corticosteroid before performing the orthopedic surgery.

A patient with mixed type Evans syndrome: efficacy of rituximab treatment.

Mixed type Evans syndrome is a very rare hematologic disease. Although mixed type Evans syndrome may initially respond well to steroids, this disease usually runs a chronic course with intermittent exacerbations. We describe here a 46-yr-old female with the steroid-refractory, mixed type Evans syndrome, and she had a prompt response to rituximab. She was diagnosed as having the mixed type Evans syndrome with the clinical features of symptomatic anemia, jaundice and thrombocytopenia. Prednisone therapy was commenced and her hemoglobin and platelet level returned to the normal. However, after 15 weeks, she relapsed with hemolytic anemia and thrombocytopenia. We started rituximab at the dose of 375 mg/m(2) once weekly for a total of 4 doses, which was well-tolerated and this induced the normalization of hemoglobin, bilirubin and lactic dehydrogenase, and there was also a significant increase of the platelet count.

Small cell carcinoma of the kidney.

Up to 5% of all small cell carcinomas develop at extrapulmonary sites. Primary small cell carcinomas originating in the kidney are extremely rare neoplasms. Here we report a case of primary small cell carcinoma of the kidney. A nephrectomy was performed on a 52-year-old female patient to remove a large tumor located in the right kidney. The histology and immunohistochemistry of the resected tumor revealed a pure small cell carcinoma with invasion into the renal capsule. The patient received postoperative adjuvant chemotherapy with etoposide and cisplatin. The patient has been monitored with regular check ups and remains stable with no recurrence at 28 months after the initial diagnosis.

In vitro efficacy of the combination of ciprofloxacin and cefotaxime against Vibrio vulnificus.

We performed time-kill studies of antimicrobial combinations that included minocycline, cefotaxime, and ciprofloxacin with Vibrio vulnificus ATCC 27562. Cefotaxime-plus-ciprofloxacin combinations acted synergistically against V. vulnificus in vitro, and this combination regimen can be a good choice as the empirical treatment for suspected necrotizing fasciitis due to V. vulnificus.

A case of focal segmental glomerulosclerosis associated with aplastic anemia.

The pathogenic mechanism of focal segmental glomerulosclerosis (FSGS) and aplastic anemia are associated with immunologic events which lead to glomerular cell injury or hematopoietic cell destruction. We present an extremely rare case of FSGS with aplastic anemia in a 30-yr-old woman. The laboratory examination showed hemoglobin 7.2 g/dL, white blood count of 4,200/ microL, platelet count 70,900/microL. Proteinuria (2+, 3.6 g/day) and microscopic hematuria were detected in urinalysis. The diagnosis of FSGS and aplastic anemia were confirmed by renal and bone marrow biopsy. She was treated with immunosuppressive therapy of prednisone 60 mg/day orally for 8 weeks and cyclosporine A 15 mg/kg/day orally. She responded with gradually improving her clinical manifestation and increasing peripheral blood cell counts. Prednisone was maintained at the adequate doses with tapering after 8 weeks and cyclosporine was given to achieve trough serum levels of 100-200 ng/mL. At review ten month after diagnosis and initial therapy, the patient was feeling well and her blood cell counts increased to near normal (Hb 9.5 g/dL, Hct 32%, WBC 8,300/microL, platelet 123,000/microL) and renal function maintains stable with normal range proteinuria (0.25 g/day).

Disseminated intravascular coagulation associated with aortic dissecting aneurysm.

Disseminated intravascular coagulation (DIC) is an acquired coagulation disorder that occurs when the normal hemostatic balance is disturbed, primarily by excessive thrombin formation. Moreover, while DIC is a rare complication of aortic dissecting aneurysm, it is also a well-recognized one. We reported a case of DIC associated with aortic dissecting aneurysm in a 55-year-old woman who was transferred from another hospital because of chest pain radiating to her back and thrombocytopenia. Laboratory findings showed DIC with severe thrombocytopenia, and she was diagnosed as having an acute aortic dissection and DIC. After medical treatment on the aortic dissecting aneurysm, her DIC profile recovered.