Multidisciplinary treatment with immune checkpoint inhibitors for advanced stage hepatocellular carcinoma

Hepatocellular carcinoma (HCC) is a cytotoxic chemotherapy-resistant tumor and most HCCs arise in a background of liver cirrhosis of various causes. Although the IMBrave150 trial showed remarkable advancements in the treatment of unresectable HCC with atezolizumab plus bevacizumab (AteBeva), therapeutic outcomes were unsatisfactory in more than half of the patients. Accordingly, many ongoing trials combine conventional modalities with new drugs such as immune checkpoint inhibitors for better treatment outcomes, and they are expected to benefit patients with limited responses to conventional treatment. Here, two patients with advanced stage HCC with preserved liver function and good performance status showed partial response after treatment with combination or sequential therapy of AteBeva, hepatic arterial infusion chemotherapy, radiation therapy, and transarterial chemoembolization. These findings indicate the efficacy of multidisciplinary treatment against advanced HCC. Additional studies are required to establish optimal treatment strategies.

Shunt Overdrainage Caused by Displacement of the Pressure Control Cam after Pressure Adjustment / 대한신경손상학회지

Although the Codman-Hakim programmable valve is one of most popular shunt systems used in the clinical practice for the treatment of hydrocephalus, malfunctions related with this system have been also reported which lead to underdrainage or overdrainage of the cerebrospinal fluid. While obstruction of the ventricular catheter by tissue materials or hematoma and catheter disconnection are relatively common, the malfunction of the valve itself is rare. Herein, we report on a rare case of shunt overdrainage caused by displacement of the pressure control cam after pressure adjustment. A 57-year-old female, who underwent a ventriculoperitoneal shunt eight years ago, experienced aggravating symptoms of shunt overdrainage after pressure adjustment. Displacement of the pressure control cam was revealed on the X-ray, and a shunt revision was performed. The purpose of this report is to provide a working knowledge of the valve structure and to enhance the ability to interpret the valve setting on an X-ray for diagnosis of valve malfunction.

Acute Pontine Infarction due to Basilar Artery Dissection from Strenuous Physical Effort: One from Sexual Intercourse and Another from Defecation

A basilar artery dissection (BAD) is an extremely rare disease. It can lead to hemorrhage or infarction involving the brain stem, and is often associated with grave outcome. However, little is known about the pathophysiology of BAD, and its proper managements are yet in controversy. Herein, we report on two rare cases of basilar artery dissection from strenuous physical effort; one from sexual intercourse and another from defecation. The treatment modalities and the outcomes are also discussed.

Acute Pontine Infarction due to Basilar Artery Dissection from Strenuous Physical Effort: One from Sexual Intercourse and Another from Defecation

A basilar artery dissection (BAD) is an extremely rare disease. It can lead to hemorrhage or infarction involving the brain stem, and is often associated with grave outcome. However, little is known about the pathophysiology of BAD, and its proper managements are yet in controversy. Herein, we report on two rare cases of basilar artery dissection from strenuous physical effort; one from sexual intercourse and another from defecation. The treatment modalities and the outcomes are also discussed.

Ultrasonographic Findings of the Shoulder in Patients with Rheumatoid Arthritis and Comparison with Physical Examination

The objectives of this study were: 1) to identify the ultrasonographic (US) abnormalities and 2) to compare the findings of physical examination with US findings in rheumatoid arthritis (RA) patients with shoulder pain. We studied 30 RA patients. Physical examination was performed systemically as follows: 1) area of tenderness; 2) range of passive and active shoulder motion; 3) impingement tests; 4) maneuvers for determining the location of the tendon lesions. US investigations included the biceps, the supraspinatus, infraspinatus, and subscapularis tendons; the subacromial-subdeltoid bursa; and the glenohumeral and acromioclavicular joints. Thirty RA patients with 35 painful and 25 non-painful shoulders were examined. The range of motion affected the most by shoulder pain was abduction. The most frequent US finding of shoulder joint was effusion in the long head of the biceps tendon. Among the rotator cuff tendons, subscapularis was the most frequently involved. Tendon tear was also common among non-painful shoulders. Physical examination used for the diagnosis of shoulder pain had low sensitivity and specificity for detecting abnormalities in the rheumatoid shoulder joint. In conclusion, US abnormalities showed frequent tendon tears in our RA patients. Physical examination had low sensitivity and specificity for detecting rotator cuff tear in the rheumatoid shoulder joint.

A Case of Renal Crisis in a Korean Scleroderma Patient with Anti-RNA polymerase I and III Antibodies

Scleroderma (SSc) renal crisis has been reported to be associated with anti-RNA polymerase I and III (RNAP I/III) antibodies in Caucasians and the Japanese. However, no report is available for Korean SSc patients. Here, we describe the case of a 65-yr-old female SSc patient who developed renal crisis and whose serum contained anti-RNAP I/III antibodies. She was finally diagnosed as having diffuse cutaneous SSc based on skin thickening proximal to the elbows and knees. Sudden hypertension, oliguria, and pulmonary edema were features of her renal crisis. Despite the use of captopril and adequate blood pressure control, her renal function deteriorated. Subsequent renal biopsy findings showed severe fibrinoid necrosis with luminal obliteration in interlobar arteries and arterioles consistent with SSc renal crisis. Serum anti-RNAP I/III antibodies were detected by radioimmunoprecipitation. This is the first report of a renal crisis in a Korean SSc patient with RNAP I/III antibodies.

Malignant Gastrointestinal Stromal Tumor of the Ampulla of Vater: A Case Report / 대한소화기학회지

GIST is a rare neoplasm, the majority of GISTs are located in the stomach and small intestine. Most GISTs are diagnosed histopathologically after resection because of submucosal location. A 37-year-old female patient presented with a 2-weeks history of generalized weakness, nausea accompanied by intermittent passage of black, tarry stools. Esophagogastroduodenoscopy and ERCP showed a large round mass measuring 5 cm in diameter in the ampulla of Vater with ulcer crack. Endoscopic multiple biopsies from the mass including ulcer base were taken. Light microscopic findings showed spindle-shaped and epitheloid tumor cells having high cellularity and frequent mitotic figures. On immunohistochemical stainings, the tumor cells were positive for CD34 and smooth muscle actin. Based on these preoperative findings, a diagnosis of malignant GIST of the ampulla of Vater was made probably. After operation, immunohistochemical studies revealed positive reaction for c-kit and vimentin, as well as focally reactive for CD34 and smooth muscle actin. We report a case of GIST in the ampulla of Vater presenting with melena that was diagnosed preoperatively and postoperatively.

The SOFA Score to Evaluate Organ Failure and Prognosis in the Intensive Care Unit Patients / 결핵및호흡기질환

BACKGROUND: The Sequential Organ Failure Assessment (SOFA) score can help to assess organ failure over time and is useful to evaluate morbidity. The aim of this study is to evaluate the performance of SOFA score as a descriptor of multiple organ failure in critically ill patients in a local unit hospital, and to compare with APACHE III scoring system. METHODS: This study was carried out prospectively. A total of ninety one patients were included who admitted to the medical intensive care unit (ICU) in Chuncheon Sacred Heart Hospital from May 1 through June 30, 2000. We excluded patients with a length of stay in the ICU less than 2 days following scheduled procedure, admissions for ECG monitoring, other department and patients transferred to other hospital. The SOFA score and APACHE III score were calculated on admission and then consecutively every 24 hours until ICU discharge. RESULTS: The ICU mortality rate was 20%. The non-survivors had a higher SOFA score within 24 hours after admission. The number of organ failure was associated with increased mortality. The evaluation of a subgroup of 74 patients who stayed in the ICU for at least 48 hours showed that survivors and non-survivors followed a different course. In this subgroup, the total SOFA score increased in 81% of the non-survivors but in only 21% of the survivors. Conversely, the total SOFA score decreased in 48% of the survivors compared with 6% of the non-survivors. The non-survivors also had a higher APACHE III score within 24 hours and there was a correlation between SOFA score and APACHE III score. CONCLUSION: The SOFA score is a simple, but effective method to assess organ failure and to predict mortality in critically ill patients. Regular and repeated scoring enables patient's condition and clinical course to be monitored and better understood. The SOFA score well correlates with APACHE III score.

A case of eosinophilic gastroenteritis with perforation due to metagonimiasis / 대한내과학회지

Eosinophilic gastroenteritis is a rare disorder, characterized by increased eosinophil count and eosinophilic infiltration in gastrointestinal organ. Its etiology is unknown, but affected by parasitic infestation, collagen disorder, malignancy and allergic disorder. There have been several reports all over the world that Eustoma rotundum, Schistosomiasis, Ancylomastoma and Ascaris are the sources of parasites occurring eosinophilic gastroenteritis. But the reports on Metagonimus yokogawai have not presented yet. We experienced a case of metagonimiasis with a presentation of small bowel perforation by eosinophilic enteritis. A 35-year-old woman was admitted to the hospital because of epigastric pain. Six months ago, she had been treated as metagonimiasis. This time she took antiparasitic agent again, but abdominal pain was aggravated and perforation of small bowel was detected. The pathologic finding of resected small bowel showed perforation and obstruction with diffuse and dense eosinophilic infiltration.

Clinical Features of Plasmodium Vivax Malaria

BACKGROUND: Since its reemergence in 1993, a number of cases of Plasmodium vivax malaria have been reported in Korea. We analyzed the cases of malaria patients living in Chuncheon and its neighboring communities, to characterize its clinical manifestations and laboratory findings, and to identify any differences between our clinical findings and those of previous studies. METHODS: We reviewed the clinical records of cases that were confirmed as malaria by peripheral blood smear at Chuncheon Sacred Heart Hospital from July 1998 to September 2001. RESULTS: Forty-four cases were included in the study. All patients were infected with Plasmodium vivax, and presented with high fever; however, tertian fever developed in only 15 patients (35.7%). A number of cases showed various symptoms, which included headache, abdominal pain, nausea and vomiting. Of the 44 cases identified, 41 (93.2%) developed malaria between June and September. Thrombocytopenia was a prominent finding in 75% of the cases at diagnosis, but resolved during or after therapy. Other laboratory abnormalities such as, anemia, elevated transamines, coagulopathies, and elevated lactose dehydrogenase (LDH) were also noted. Cerebrospinal fluid (CSF) studies were performed in five cases, one of which showed pleocytosis in the CSF. CONCLUSION: We noted only 15 patients (35.7%) with tertian fever; the other patients showed variable fever patterns. Thrombocytopenia was the most prominent laboratory finding. Therefore, we suggest that malaria should be included in the differential diagnosis of febrile diseases with an onset between June to and September, regardless of the pattern of the fever.

A Case of Anorectal Actinomycosis / 대한소화기내시경학회지

Actinomycosis is an indolent, slowly progressive infection caused by actinomyces species that normally colonize the mouth, colon, and vagina, characterized by sulfur granule formation. Actinomycosis can affect multiple organs, with local or systemic manifestations. The abdomen is involved in less than 20% of the cases with the ileocecal area being the site most frequently affected. The anorectal region is less frequently involved. We report a case of anorectal actinomycosis, which was diagnosed by histologic study of sigmoidoscopic biopsy. The patient was a 40-year-old man who took immunosuppressive agents after kidney transplantation. Adequate surgical excision was done, being followed by administration of massive dose of a penicillin.

A case of primary endobronchial actinomycosis associated with a foreign body / 대한내과학회지

Actinomycosis is an indolent, slowly progressive infection caused by anaerobic bacteria, primarily of the genus Actinomyces, that colonize the mouth, colon, and vagina. A vital step in the development of actinomycosis is disruption of the mucosal barrier. Actinomycosis occurs most frequently at a cervicofacial, abdominal, and pelvic region. Thoracic actinomycosis usually follows an indolent progressive course with involvement of the pulmonary parenchyma and/or the pleural space. Rarely, pulmonary nodules or endobronchial lesions can occur. We report a case of a 62-year-old woman of chronic cough with sputum and pulmonary mass with consolidation at the right lower lobe on chest radiography. Fiberoptic bronchoscopic findings revealed a polypoid tumor like mass completely obstructing RLL lobar bronchus and a hard bony material embedded there. Histologic examination of the biopsy specimens demonstrated acute and chronic inflammation with calcified material and a sulfur granule, which led to the diagnosis of endobronchial actinomycosis. The patient responded to several bronchoscopic procedures and intravenous penicillin G.

A case of primary endobronchial actinomycosis associated with a foreign body / 대한내과학회지

Actinomycosis is an indolent, slowly progressive infection caused by anaerobic bacteria, primarily of the genus Actinomyces, that colonize the mouth, colon, and vagina. A vital step in the development of actinomycosis is disruption of the mucosal barrier. Actinomycosis occurs most frequently at a cervicofacial, abdominal, and pelvic region. Thoracic actinomycosis usually follows an indolent progressive course with involvement of the pulmonary parenchyma and/or the pleural space. Rarely, pulmonary nodules or endobronchial lesions can occur. We report a case of a 62-year-old woman of chronic cough with sputum and pulmonary mass with consolidation at the right lower lobe on chest radiography. Fiberoptic bronchoscopic findings revealed a polypoid tumor like mass completely obstructing RLL lobar bronchus and a hard bony material embedded there. Histologic examination of the biopsy specimens demonstrated acute and chronic inflammation with calcified material and a sulfur granule, which led to the diagnosis of endobronchial actinomycosis. The patient responded to several bronchoscopic procedures and intravenous penicillin G.

Clinical features of Plasmodium vivax malaria / 대한내과학회지

BACKGROUND: Since Plasmodium vivax malaria reemerged in Korea in 1993, a number of patients with malaria have been reported. We analyzed the cases with malaria who lived in Chuncheon and neighboring communities to find out clinical manifestations, laboratory findings and the differences in clinical findings compared to previous studies. METHODS: We reviewed the clinical records of the cases who were confirmed as malaria by peripheral blood smear in Chuncheon Sacred Heart Hospital from July, 1998 to Octorber, 2001. RESULTS: Forty-four cases were included. All cases were Plasmodium vivax with high fever, but tertian fever developed only in 15 patients (35.7%). A number of cases showed various symptoms including headache, abdominal pain, nausea, vomiting. Of the all cases, 41 cases (93.2%) developed malaria between June and September. Thrombocytopenia was prominent finding which was noted in 75% of the cases at diagnosis, and recovered during or after treatment. Other laboratory abnormalities such as anemia, elevated transaminases, coagulopathies, and elevated LDH level were also noted. Five patients were performed CSF studies, one patient showed pleocytosis in CSF. CONCLUSION: We observed that only 15 patients (35.7%) had tertian fever, the others had variable fever patterns. Thrombocytopenia was the prominent findings. Therefore we suggest that malaria should be included in the differential diagnosis of febrile diseases which developed from June to September regardless of the fever patterns.