Hodgkin's Lymphoma after Autologous Hematopoietic Stem Cell Transplantation for Angioimmunoblastic T-cell Lymphoma / 대한내과학회지

Post-transplantation lymphoproliferative disorder (PTLD) is a serious complication that can develop after either solid organ or hematopoietic stem cell transplantation (HSCT). The incidence of Hodgkin's lymphoma (HL) ranges from 0.5-1.0% of PTLD after HSCT without T-cell depletion. Here, we report a case of HL-PTLD that occurred after autologous peripheral blood stem cell transplantation for an angioimmunoblastic T-cell lymphoma (AITL). A 36-year-old patient developed fever and chills with multiple lymphadenopathies at day 673 after auto-HSCT for AITL. Three months after the transplant, the patient developed fever with elevated plasma Epstein-Barr virus (EBV)-PCR values. The excisional biopsy revealed HL at Ann Arbor stage IIIB. A total of 8 cycles of chemotherapy with ABVD please define were performed, and the patient has remained disease-free. To our knowledge, this is first case report of HL-PTLD after auto-PBSCT in Korea.

A Case of an Extragastrointestinal Stromal Tumor of the Pelvic Cavity Presenting with Hematuria / 대한내과학회지

Although gastrointestinal stromal tumor (GIST) is the most common mesenchymal tumor of the gastrointestinal tract, it also occurs in the non-gastrointestinal tract, and is referred to as extragastrointestinal stromal tumor (EGIST). In this report, we describe a 48-year-old female patient who presented with hematuria, and who was finally diagnosed with a primary extragastrointestinal stromal tumor of the pelvic cavity involving the bladder, vagina and left ureter. Tumor cells were positive for immunohistochemical staining for CD117 antigen (proto-oncogene protein c-kit), CD34, and vimentin, whereas they were negative for desmin, smooth muscle actin, and S-100 protein. These findings provide histopathological and immunohistochemical evidence for diagnosing this tumor as EGIST.

Fluoroscopy-Assisted Thromboembolectomy

PURPOSE: Acute limb ischemia continues to be a challenge with high amputation and mortality rates. Conventional thrombectomy allows rapidly removing thrombi, yet this is a blind procedure and it is prone to damage arteries during the operation. In 1996, operative fluoroscopy and over-the-wire (OTW) catheters were reported to allow safe removal of thrombus in patients with acute limb ischemia. We have recently adopted the procedure and we report on our results. METHODS: During the past one year, we treated 7 patients who had acute or subacute lower limb ischemia. Under general or local anesthesia, the femoral artery was exposed and a sheath was inserted. Under fluoroscopy, a guidewire was passed through the thrombus; then a Fogarty Thru-lumen catheter (TLC) was passed into the lesion and thrombectomy was performed. RESULTS: Four patients were female and three were male. Their ages ranged 55 to 79. The symptom duration was within 10 days for five patients, and 1 and 2 months for two others, respectively. The ischemic severity was class I in two patients, IIa in four and IIb in one. There were two iliac occlusions and five femoral-popliteal occlusions. The occlusion length ranged from 5 to 47 cm. Local anesthesia was done for 6 patients. Removal of thrombus was complete or nearly complete in 6 patients, and this was partial in 1 due to rupture of the posterior tibial artery. Additional balloon angioplasty was performed in one patient. All the symptoms resolved in all but one patient, who had persistent foot ischemia. One patient died 2 months later due to liver failure. CONCLUSION: Fluoroscopy-assisted thrombectomy was quite helpful for safely removing thrombi.

The Anatomical Properties of Size of Abdominal Aorta in Korean Normal Adult Populations

PURPOSE: The diameter of the abdominal aorta is an important criterion for making the diagnosis of abdominal aortic aneurysm. But the diagnostic criteria for the aortic diameters and the aneurysms are based on western people' s data, and there is scant data on this for Koreans. In this study, we measured a normal range of the abdominal aortic diameter of Korean adults and we classified the diameters according to age, gender and the body mass index (BMI). METHODS: The data is based on 496 patients (male: 281, female: 215) who had no evidence of vascular disease on abdominal multi detector computed tomography exams that were been done between October through December of year 2007 at our hospital. The abdominal aorta was measured at the smallest outer diameter of the infrarenal aorta and the upper bifurcation level. The age of the patients was from 20 to 70 years-old and the patients were divided into 6 groups by age. The patients were also divided into three groups according to their BMI (the low weight, normal weight and over weight groups). We computed the average and standard deviation of the aortic dimensions from each group. RESULTS: The average diameter at the infrarenal aorta was 18.32 mm and that at the upper bifurcation level was 17.25 mm. The males' average aortic diameter at the infrarenal aorta and at the upper bifurcation level was 19.23 mm and 18.10 mm, respectively, and those values for the females were 17.09 mm and 16.20 mm, respectively. In both the males and females, the diameter increased with increasing patient age (P<01). For the BMI, the diameter was larger for the higher BMI group. CONCLUSION: For the normal Korean population, the diameter of the abdominal aorta increases with aging and with an increased BMI, but the changes were relatively smaller as compared with the western normal range. More studies are needed to determine Koreans' normal range of the diameter of the abdominal aorta and this data can be applied to the diagnosis and treatment of abdominal aortic aneurysm.

Endovascular Aortic Aneurysm Repair in a Renal Transplant Recipient:a Case Report

Endovascular aneurysm repair (EVAR) has gained increasing acceptance and success. We report here on a case of EVAR in a patient with renal allograft. EVAR was performed using an aorto-biiliac endovascular graft system in a 65-year-old man who underwent kidney transplantation in the right iliac fossa. The donor renal artery was anastomosed to the recipient' s internal iliac artery. The preoperative renal function was normal. The size of the aneurysm was 5.5 cm in transverse diameter and the length of the distal neck was 2 cm to the right internal iliac artery. After the procedure, the completion angiogram demonstrated the good position of the endograft; however, we found a type II endoleak from the IMA. The postoperative renal function was not changed and the patient was discharged home after an uneventful hospital course. At the 6 month follow-up, the type II endoleak was noted to have decreased on the CT angiogram and the patient has remained well with a stable allograft renal function.

Bilateral Persistent Sciatic Arteries with Unilateral Complication:a Case Report

The sciatic artery is a major artery of the lower limb bulb during the early embryonic period. Its failure to regress is sometimes associated with femoral artery hypoplasia, and therefore, the dominant inflow to the lower extremity is called a persistent sciatic artery (PSA). This anomaly is often associated with a higher rate of aneurysm formation or thromboembolic complications that cause lower extremity ischemia. A 51-year-old man presented with complaints of right calf pain and a several month history of progressive claudication. CT angiography showed bilateral PSAs originating from hypogastric arteries. A long segment of the right PSA showed aneurysmal dilatation and thrombotic occlusion and the superficial femoral artery showed hypoplastic change. Focal segmental occlusion of the right popliteal artery below the knee was seen. He received a right femoro-posterior tibial bypass with a reversed saphenous vein graft. The patient' s postoperative course was uneventful and no complications were observed at 16 weeks follow-up.

A Case of Gastric Adenocarcinoma Presenting as Meningeal Carcinomatosis

Leptomeningeal carcinomatosis occurs in approximately 5% of patients with cancer. The most common cancers involving the leptomeninges are breast, lung cancer and melanoma. However, gastric adenocarcinoma has been rarely reported with leptomeningeal carcinomatosis. The presenting manifestations are usually headache, visual disturbances and seizures. We report a case of leptomeningeal metastasis that presented as a gastric cancer. A 49-year-old woman was admitted to our hospital with the symptoms of headache and melena for 10 days. The endoscopy showed a thickening of the folds of the stomach compatible with the diagnosis of a Borrman type IV gastric cancer. The biopsy revealed a signet ring cell carcinoma. The MRI of brain showed no abnormal findings; however, the patient complained of an intractable persistent headache, nausea and vomiting on admission day 6. The cytology examination of the cerebrospinal fluid supported the diagnosis of metastatic signet ring cell carcinoma.

Plaque Morphology of Popliteal Arteries: A Study Using Intravascular Ultrasound

PURPOSE: Intravascular ultrasound (IVUS) provides detailed images of vessels. The medical literatures is rich with research regarding the use of IVUS for both endovascular treatment and the morphologic evaluation of coronary arterial and aortic plaques. This study aimed to characterize the morphologic properties of the popliteal arteries with using IVUS. METHOD: Eighteen popliteal arteries from amputated legs were pressure- perfused and the pullback images were obtained with 20 MHz IVUS catheters along an average length of 40.8 mm (+/-10.6 mm, SD) of artery. The video images were analyzed for the luminal and medial- adventitial borders, and the various morphologic parameters of the plaques were determined. RESULT: The mean Vessel diameter was 6.5 mm (+/-1.0 mm) and luminal diameter was 3.8 mm (+/-0.9 mm). The areas for the vessels, lumens and plaques were 30.7 (+/-10.0), 9.5 (+/-5.0) and 21.2 (+/-7.1) mm2 respectively, and the mean percent area stenosis was 69.4% (+/-9.8%). Vessel area correlated positively with the plaque area in 16 specimens (correlation coefficient of the pooled data, r=0.89, P<0.01), and the luminal area in 14 specimens (r=0.75), it was negatively correlated with the percent area stenosis in 11 out of 18 arteries (r=-0.09). CONCLUSION: These results show the details of morphologic changes in severely stenosed popliteal arteries. The vessel area is influenced by both the plaque area and the luminal area.

Delayed Superficial Transposition of Cephalic Vein for Salvage of Brachiocephalic FIstula

The small diameter and sclerosis of the veins are the main causes of failure of autogenous arterio-venous fistula(AVF) for hemodialysis. In addition, the deep location of veins prevents adequate access postoperatively, as exemplified by the frequent requirement of transposition of basilic veins either primarily or delayed. As for the cephalic veins, superficial transposition was not emphasized. We report a case of brachiocephalic AVF which required delayed superficial transposition for access. We emphasize that the depth of veins should be considered for adequate creation of AVF.

Penetrating Injury of Inferior Vena Cava by Abdominal Stab Wound

Injuries of the inferior vena cava (IVC) might be caused by a blunt trauma, which usually affects the retrohepatic portion. Injuries of the infrahepatic IVC are usually caused by penetrating injuries and rarely occur in Korea. We report a case of a penetrating injury of the IVC at the infrahepatic suprarenal portion with a review of other reported cases.

Two cases of acute toxic hepatitis and renal failure after ingestion of the extract of elm bark in lung cancer patients / 대한내과학회지

Traditional remedies, especially the extract of elm bark, are frequently used in Korea. But the exact efficacy and adverse effects are not known. Cancer patients are frequently recommended various traditional remedies by family members. However such remedies may lead to life-threatening complications. We observed two cases of severe hepatic and renal toxicities that developed after ingestion of elm extract. One patient was a 67-year-old man diagnosed with stage IV non-small cell lung cancer (NSCLC). He ingested the bark extract of elm for 2 weeks during routine work-up prior to chemotherapy. He abruptly showed acute toxic hepatitis with cardiac tamponade. The other patient was a 57-year-old woman diagnosed with extensive disease-small cell lung cancer (ED-SCLC). She consumed the extract of root bark of elm for 5 months during complete remission status and developed acute renal failure. These cases suggest that use of the extract of elm bark in cancer patients must be more careful.

Tuberculous Pseudoaneurysm of the Infrarenal Abdominal Aorta: 1 case report

Tuberculous pseudoaneurysm of the abdominal aorta (TBAA) is an exceedingly rare, but fatal complication of the tuberculosis, especially in the condition of the disseminated tuberculosis. We reported a case of TBAA treated successfully by surgical and medical therapy. A 65-year-old woman admitted to our hospital complaining of sudden abdominal pain, nausea and vomiting for 3 days. She underwent 4 times operation of orthopedic surgery for tuberculous spondylitis at the level of the L4-5, T5-7, tuberculous epidural abscess, both psoas abscess, and had been receiving antituberculous medications for disseminated miliary tuberculosis at the both lung fields. Soon after this, she developed aggravated abdominal pain and we examined contrast enhanced abdominal CT scan and revealed saccular, thrombosed aneurysmal dilatation on the level of the aortic bifurcation. We performed elective operation for direct closure of the small rent at the anterior wall of the abdominal aorta after confirming no active inflammatory reaction on the frozen biopsy. Currently, the patient is an antituberculous medications without any surgical complication for 12 months after operation.

The Rupture of Distal Superficial Femoral Arterial Aneurysm on Rheumatoid Arthritis Patient

Isolated true atherosclerotic aneurysm of the distal superficial femoral artery is rare disease. We experienced a case of distal superficial femoral artery aneurysm not associated with dilatation of the common femoral or popliteal artery. True arterial aneurysms are attributed to the weakening of the arterial wall due to atherosclerosis. True superficial femoral artery aneurysms were predominantly founded in elderly men and used to be diagnosed by ultrasonography, CT or angiogram. We report a case of distal superficial femoral arterial aneurysmal rupture in elderly woman who has a rheumatoid athritis and diagnosed by ultrasonography. We performed aneurysmal excision and interposition graft with PTFE.

Paraplegia with Rapid Deterioration in a Thrombocytopenic Patient: A Case Report of Acute Aortic Thrombosis

Acute aortic occlusion is rare but poses a high mortality and morbidity. Prompt diagnosis and treatment is essential. Typical presentation is rest pain with bilateral absent femoral pulse. When the non-typical symptoms predominate such as paraplegia, acute abdomen or sudden-onset hypertension, diagnosis may be difficult. We experienced a case of acute aortic thrombosis who suddenly developed paraplegia and rapidly deteriorated within several hours. When the paraplegia developed, he was under treatment with heparin and urokinase, was thrombocytopenic, and the femoral arteries were pulsatile. Spinal cord compression due to bleeding complication had to be ruled out. Duplex sonography and lumbar CT scan were not diagnostic. Aortic thrombosis was diagnosed by abdominal CT scan. This case illustrates the need for high suspicion of acute aortic occlusion presenting with paraplegia especially in patients with associated atherosclerotic disease.

Fourier Analysis of Doppler Arterial Waveforms of Lower Extremity

PURPOSE: Although it is well known that the pulsatile Doppler waveforms change in shape with disturbed flow, interpretation of the waveforms has largely been subjective. We aimed to describe the Doppler waveforms of the lower extremity objectively by parameters of Fourier transformation. METHOD: Sixty-eight Doppler arterial waves were analyzed in this study. They were classified according to the clinical findings; Group I: no ischemic symptoms with ankle pressure>100 mmHg (N=17). Group II: no ischemic symptoms with ankle pressure 80~100 mmHg (N=18). Group III:symptoms of claudication (N=19). Group IV: rest pain or tissue loss (N=14). The waveforms were Fourier transformed and their amplitudes and phases were compared up to the third harmonics. RESULT: Both the fundamental and second harmonics were predominant in group I. In contrast, fundamental harmonic was predominant with disturbed flow. The phases of the fundamental and second harmonics were delayed with disturbed flow. Relative phase (difference of phase between higher harmonics and fundamental harmonic) tended to be shortened with disturbed flow. CONCLUSION: Abnormal waveforms are characterized by predominant amplitude of the first harmonic, phase delay, and shortening of the relative phase. These parameters may be useful for differentiation of Doppler waveforms.

Use of Preoperative Duplex Scan for Hemodialysis Fistula Operations: Early Results

PURPOSE: We assumed preoperative duplex examination may be helpful for determination of the site of hemodialysis fistula operation and result in decreased early failures. METHOD: From January 1999 through October 1999, 25 operations were performed in 23 patients (historical control, Group I). From November 1999 through June 2000, 30 operations were performed in 29 patients (Group II). During the latter period, preoperative duplex examination was selectively introduced for patients whose forearm veins were not prominent or who were suspected to have stenosis or obstruction of outflow. Forearm veins with a diameter more than 2.5 mm were sought and their continuity up to the elbow level was confirmed. When an adequate forearm vein was not detectable, veins on antecubital area with the diameter more than 4 mm was sought for graft fistula (GF). RESULT: Group I consisted of 24 autogenous fistulas (AF) and 1 GF, and group II consisted of 26 AF and 4 GF. Among the group II patients, 19 preoperative duplex examinations were done (18 patients). The mean diameter of forearm veins used for AF were 3.27mm (0.69 SD). Diameter of veins used for GF ranged from 3.7 to 6.0 mm. Early failure rate in group I was 16% (4/25), whereas it was 6.7% in group II (2/30). The two failures in group II were associated with sclerotic veins on physical examination. CONCLUSION: Our early results show that preoperative duplex scan may decrease early failure rate of fistula operation. Findings of duplex scan combined with avoidance of sclerotic veins on physical examination may significantly decrease the rate of early failure.

Risk Factors and Prophylactic Anticoagulation Therapy of Deep Vein Thrombosis in Lower Extremity

PURPOSE: Deep vein thrombosis of the lower extremity is a frequent disorder which may either occur spontaneously or following a high-risk situation such as major surgical procedures or prolonged period of immobilization. Untreated deep vein thrombosis is associated with morbidity and mortality due to pulmonary embolism and the postthrombotic syndrome. Factors in predicting the risk of deep vein thrombosis can be influenced by the variations of the medical and surgical conditions associated with it. Within the last few years, the knowledge of hereditary and acquired risk factor for deep vein thrombosis have increased, but yet not justified. METHOD: We describe why certain individuals develop deep vein thrombosis at varying times despite of similar risk factors, and also assess risk stratification as well as the value of thromboprophylaxis in medical and surgical patients. From January 1990 to December 1998, 73 patients who have developed deep vein thrombosis were admitted to our hospital. The patients' charts were reviewed retrospectively about risk factors according to age, site, associated medical and surgical conditions. RESULT: The older patients who have developed deep vein thrombosis generally had systemic disease, however the younger patient who have developed deep vein thrombosis had trauma, operation, previous deep vein thrombosis. The duplex scan was sufficient and accurate modality for diagnosis of deep vein thrombosis. CONCLUSION: The patients with risk factor may need to be under close observation and when deep vein thrombosis is diagnosed, prophylactic anticoagulation therapy may be beneficiary for patient's prognosis and pulmonary embolism prevalence. Further clinical research may be needed to help develop accurate methods of risk stratification and to clarify the benefits of thromboprophylaxis in high risk group.

A Salvaging Procedure with Composite Graft Configuration in Poor Outflow Arterio-Venous Fistula for Hemodialysis: Report of Two Cases

Maturation failure after creation of autogenous arterio-venous fistula (AVF) is closely related to unrecognized stenosis or sclerosis of outflow veins. To address this problem, we chose to salvage a segment of venous conduit. A 51 year-old male patient underwent an AVF operation at the snuffbox. Postoperatively, fistula flow was not well developed on the upper forearm despite venous dilatation up to the dorsal radial branch of cephalic vein. After 3 weeks, a graft was inserted between the dilated cephalic vein and antecubital vein. The other patient was a 71 year-old man who underwent an AVF operation above the left wrist. Despite partial dilatation of veins near the anastomosis, flow was not well developed on the upper forearm. After 8 days, a graft was inserted between the dilated cephalic vein and antecubital vein. In summary, we interposed a segment of synthetic graft between dilated veins for primary maturation failure of autogenous AVF. This composite graft configuration may have advantage over total graft configuration, which should be confirmed by further study.

Carpal Tunnel Syndrome in Chronic Renal Failure Patients Undergoing Continuous Ambulatory Peritoneal Dialysis(CAPD) / 대한신장학회잡지

BACKGROUND: Carpal tunnel syndrome(CTS) is a long-term complication in dialysis patients which results from compression of the median nerve within the carpal tunnel. It has been reported to occur with increased frequency in the hemodialysis population, but, there are few reports concering long-term complications in CAPD because of the relatively shorter duration of dialysis in most CAPD patients. The aim of this study was to determine the incidence of CTS in patients undergoing CAPD. METHODS: We analyzed 21 chronic renal failure (CRF) patients(males 14, females 7; age range 19-79 yr) undergoing CAPD. The patients were evaluated by questionnare, physical examination, and nerve conduction test(NCT). Age, gender, duration of CRF before CAPD, duration of CAPD, diabetic history were determined. RESULTS: Among the total 21 patients undergoing CAPD, only 5 patients(24%) were CTS, diagnosed by NCT. Two of these patients were symptomatic CTS, three patients were non-symptomtic CTS. So, there were no relationship between the incidence of CTS and clinical symptoms. Among the diabetic dialysis patients, the incidence of CTS was 28.57%. Also there was no increase in the number of diatetic patients with CTS. CONCLUSION: It is concluded that the incidence of CTS in CAPD patients was similar with the previous reported incidence(2-31%) of hemodialysis patients. Since CTS is treatable, annual or even semiannual nerve conduction tests is indicated all CRF patients on chronic dialysis.

Two cases of small cell lung cancer with bony metastases diagnosed with FDG - PET despite a normal planar bone scan / 대한내과학회지

Bone scintigraphy is a very sensitive and cost-effective diagnostic method for detecting bony metastases of malignant neoplasm. However it has been reported that bone scan is less sensitive for early bony metastases, especially vertebral metastases. PET is a non-invasive clinical imaging methodology that can be used to assess such biochemical disturbance in tissue in vivo quantitatively with high resolution.We experienced two cases of small cell lung cancer with multiple bony metastases which were detected on PET imaging but not on planar bone scan. This case report suggests that FDG-PET will be a very effective diagnostic tool for bony metastases especially in clinically suspected case despite a normal planar bone scan.