증례 : JAK2 돌연변이를 갖는 진성적혈구 증가증과 무증상 다발성 골수종이 동반된 1예

정윤화 ( Yun Hwa Jung ),우인숙 ( In Sook Woo ),한상봉 ( Sang Bong Han ),이제훈 ( Je Hoon Lee ),한치화 ( Chi Wha Han ) 대한내과학회 2013 대한내과학회지 Vol.84 No.2

저자들은 JAK2V617F 돌연변이를 동반한 진성적혈구증가증 환자에서 무증상 다발성골수종이 병발한 증례를 경험하였기에 문헌고찰과 함께 흥미로운 증례로 보고한다. The lymphoproliferative disease multiple myeloma and the myeloproliferative disease polycythemia vera have different pathogenic mechanisms and different natural courses. Thus, the concomitant development of these two diseases in the same individual is rare. In most previously reported cases of both diseases, one disease was assumed to be a secondary malignancy caused by chemotherapy for the other primary disease. Our case was diagnosed as smoldering myeloma based on increased bone marrow plasma cell numbers and monoclonal gammopathy during a regular follow-up visit for JAK2V617F mutation-positive polycythemia vera, which had not been treated except with phlebotomy. This case provides useful clues for understanding the pathogenesis of these two hematological malignancies and the association between them. Here, we report a case of polycythemia vera with a JAK2V617F mutation combined with smoldering myeloma and discuss the clinical significance and pathogenic association between these disorders of different lineages, along with a literature review. (Korean J Med 2013;84:308-312)

증례 : 혈액종양 ; 담낭암 환자에서 발생한 비정형성 베르니케 뇌병증 1예

정윤화 ( Yun Hwa Jung ),유현아 ( Hyun Ah Yu ),윤건중 ( Gun Jung Youn ),이자인 ( Ja In Lee ),우인숙 ( In Sook Woo ),한치화 ( Chi Wha Han ) 대한내과학회 2013 대한내과학회지 Vol.84 No.4

담낭암 환자에서 갑작스럽게 발생한 구음장애와 보행실조에 대한 평가를 위해 시행한 뇌자기공명영상에서 치상핵에 국한된 신호강도 변화를 보여 metronidazole 유발성 뇌병증과의 감별이 어려웠으나 thiamine 선제 치료 후 증상과 영상학적 호전을 보여 비정형성 베르니케 뇌병증으로 진단할 수 있었던 증례를 문헌고찰과 함께 보고한다. Wernicke`s encephalopathy (WE) is an acute neuropsychiatric syndrome resulting from thiamine deficiency. Traditionally, diagnosis of WE rests on a clinical symptom triad consisting of ocular signs, altered consciousness, and ataxia. However, the complete triad is only present in a fraction of cases, which means that WE tends to be under-diagnosed, especially in nonalcoholic patients. Brain MRI of WE patients usually shows symmetrical signal intensity alterations in the thalami, mammillary bodies, and periaqueductal area, because of cytotoxic edema in the same region. These typical findings are useful diagnostic leads in WE patients with atypical symptoms. However, atypical findings can occasionally be seen in the vermis of cerebellum and cerebellar nuclei. Notably, alterations of signal intensity in the cerebellar dentate nuclei, which is a typical finding of metronidazole-induced encephalopathy (MIE), need to be distinguished according to medication history and response to thiamine. (Korean J Med 2013;84:602-607)

Hip Arthroplasty in Aplastic Anemia

Yong Sik Kim(김용식),Chi Hwa Han(한치화),Doo Hoon Sun(선두훈),Ki Won Kim(김기원),Hwa Sung Lee(이화성),Jin Hong Cheon(천진홍),Young Kyun Woo(우영균) 대한정형외과학회 1997 대한정형외과학회지 Vol.32 No.6

동종 골수 이식 환자의 감염 양상

신완식(Wan Shik Shin),한치화(Chi Hwa Han),유석환(Suk Hwan Yoo),박종원(Chong Won Park),강문원(Moon Won Kang),김춘추(Choon Choo Kim),김동집(Dong Jip Kim),정희영(Hee Young Chung),김학기(Hak Ki Kim),최일봉(Il Bong Choi) 대한내과학회 1991 대한내과학회지 Vol.41 No.1

N/A We studied, retrospectively, the patterns of infection in 50 febrile, allogeneic bone marrow transplantation patients during the period from March 1983 to February 1989 at St. Mary's Hospital. The results were as follows: 1) Out of 50 patients, 35 were diagnosed with leukemia and 15 with aplastic anemia. In the leukemic patients, 11 had acute lymphocytic leukemia, 12 had acute myelogenous leukemia, and 12 had chronic myelogenous leukemia. 2) There were a total of 99 febrile episodes. Thirtyseven episodes (37. 4%) were during the early post-bone marrow transplantation before engraftment (<3-4 wks), 22 episodes (22.2%) during after-engraitment period (<100 days), 29 episodes (29.3%) during the late post-transplantation period, and 11 episodes (11.1%) during the pre-transplantation period. 3) Frequent sites of infection were in the lung (24 episodes, 42.7%), in the blood (10 episodes, 16.9%), and in the skin and soft tissue (7 episdodes, 11.9%) in decreasing order of the total documented infection, and 30 cases (30.3%) were microbiologically documented infections, while 29 cases (29.3%) were clinically documented infections. 4) The radiologic patterns of lung infiltration revealed the interstitial type to be the most frequent (14 cases, 58.4%). The nodular and the consolidation type of pattern were also present (5 cases, respectively). 5) The causative organisms for microbiologically documented infection were Gram negative organisms in 14 cases (34.1%), Gram positive organisms in 13 cases (31.7%), fungus in 6 cases (14.7%), M. tuberculosis in 2 cases (4.9%), and mixed organisms in 6'cases (14.6%). 6) Out of a total of 1420 cases of surveillence culture, organisms were cultured in 164 of these cases (11.5%), the positive cultures were from the oropharynx with 37 cases (22.8%), the axilla with 32 cases (19.5%), and the groin with 25 cases (15.2%). 7) Deaths in the patient population were due to complications of infection (1 case), graft failure (2 cases), graft rejection (2 cases), relapse of disease (5 cases), renal failure (1 case), and veno-occulsive disease (1 case). Rapid diagnosis, powerful treatment and the prevention of infection after bone marrow transplantation are thought to be able to reduce the number of deaths. In the future, further research and techniques aimed at preventing and treating viral infections need to be estabilished.

증례 : 혈액종양 ; 50대 남자 환자에서 대세포 폐암으로 오인된 원발성 종격동 융모막암 1예

김영신 ( Young Shin Kim ),한치화 ( Chi Wha Han ),정윤화 ( Yun Hwa Jung ),정민영 ( Min Young Jeong ),고성우 ( Seong Woo Go ),윤경진 ( Kyung Jin Yun ),정한희 ( Han Hee Chung ) 대한내과학회 2014 대한내과학회지 Vol.86 No.5

남자에서 발생된 성선 외 융모막암은 매운 드문 종양으로 종격동에서 발생하는 경우 폐암이나 호지킨 림프종으로 오인되기 쉽다. 특히 일반적인 나이를 비롯하여 전이 방식 등 생식세포암의 임상적 특징을 보이지 않는 경우와 경피적 침생검에서 분화도가 좋지 않은 상피암 형태로 관찰되는 경우 진단이 지연될 수 있다. 저자들은 50대의 남자에서 경피적 생검 결과 대세포 폐암이 의심되어 절제술을 시행한 후 원발성 종격동 융모막암으로 진단된 1예를 경험하였기에 교훈적인 증례로 보고하는 바이다. Primary mediastinal choriocarcinoma is an extremely rare extragonadal germ cell malignancy. A 58-year-old male presented with a lung mass, which was incidentally discovered during a periodic medical checkup. Percutaneous needle biopsy showed poorly differentiated carcinoma with large pleomorphic morphology. After the patient underwent right upper lobectomy and lymphadenectomy, the final diagnosis was choriocarcinoma. The patient received four sequential cycles of BEP chemotherapy (bleomycin, etoposide, cisplatin). After completion of BEP chemotherapy, follow-up positron emission tomography (PET) showed a complete metabolic response. Although the mediastinum is one of the most common primary sites of extragonadal germ cell tumors, primary mediastinal choriocarcinoma is liable to be misdiagnosed as lung cancer or Hodgkin lymphoma. Notably, large cell carcinoma of the lung can be confused with choriocarcinoma even after percutaneous needle biopsy. We report a case of primary mediastinal choriocarcinoma mimicking large cell carcinoma of the lung in a male patient in his 50s. (Korean J Med 2014;86:641-646)

증례 : 혈액종양 ; 림프종 환자에서 리툭시맙 치료 후에 발생한 저감마글로불린혈증 1예

노현진 ( Hyun Jin Noh ),공봉한 ( Bong Han Gong ),김영신 ( Young Sin Kim ),정윤화 ( Yun Hwa Jung ),우인숙 ( In Sook Woo ),한치화 ( Chi Wha Han ) 대한내과학회 2014 대한내과학회지 Vol.87 No.3

Rituximab, an anti-CD20 monoclonal antibody, is an effective target agent against the B lymphocytes in B-cell lymphoid malignancies and various lymphoproliferative diseases. Moreover, the toxicity of rituximab is less severe than that of conventional cytotoxic agents, which has promoted the widespread application of rituximab in the treatment of B-cell lymphoma. However, depletion of B lymphocytes by rituximab, which leads to secondary hypogammaglobulinemia, can cause deterioration of humoral immunity. Although immune reconstitution after hematopoietic stem cell transplantation is known to prevent prolonged hypogammaglobulinemia, very few cases of long-standing hypogammaglobulinemia have been reported. We report herein a case of prolonged hypogammaglobulinemia after rituximab-containing chemotherapy and splenectomy in a patient with non-Hodgkin`s lymphoma and discuss the clinical significance and pathogenetic mechanism of this phenomenon with a literature review. (Korean J Med 2014;87:357-362)

혈액종양 : 원발성 식도 미만성 거대 B세포 림프종 2예: 치료와 문헌적 고찰

김지혜 ( Ji Hye Kim ),정윤화 ( Yun Hwa Jung ),우인숙 ( In Sook Woo ),한치화 ( Chi Wha Han ),서민우 ( Min Woo Seo ),유상훈 ( Sang Hoon Yoo ),하소영 ( So Young Ha ) 대한내과학회 2015 대한내과학회지 Vol.88 No.2

Primary esophageal lymphoma is very rare, and most reported cases are histologically mucosa-associated lymphoid tissue lymphoma. Therefore, the principle treatment strategy for primary esophageal lymphoma focuses on local treatments, such as endoscopic mucosal resection or radiation therapy, but systemic chemotherapy plays the central role in the treatment of diffuse large B cell lymphoma (DLBCL). Generally, standard treatment for DLBCL is six or three cycles of R-CHOP chemotherapy followed by involved field radiation therapy according to stage. However, the optimal treatment strategy for primary esophageal DLBCL, and the role of additional radiation is not settled, due to a paucity of cases. Moreover, the clinical characteristics related to the etiology and natural course are also unknown. Here, we present two cases of primary esophageal DLBCL with a literature review. (Korean J Med 2015;88:224-230)

증례 : 혈액종양 ; Erlotinib과 Warfarin의 동시 투여로 PT-INR이 연장된 1예

김승경 ( Seung Kyoung Kim ),박경선 ( Kyung Seon Park ),최승화 ( Seung Hwa Choi ),변재호 ( Jae Ho Byun ),우인숙 ( In Sook Woo ),한치화 ( Chi Hwa Han ),김효림 ( Hyo Lim Kim ) 대한내과학회 2011 대한내과학회지 Vol.80 No.6

향후 활동성이 저하된 진행성 비소세포폐암 환자에서 EGFR TKI 표적치료제와 와파린을 병용하는 사례가 더욱 증가할 것으로 예상되므로 이들 약제의 잠재적인 상호작용을 고려하여 INR의 변화를 주의 깊게 관찰해야 하며 필요한 경우에는 와파린의 용량을 조절해야 한다. Erlotinib, an orally active epidermal growth factor receptor (EGFR) tyrosine kinase inhibitor (TKI), is indicated for EGFR mutation-positive patients with poor performance status. Erlotinib is also used as a second-line agent in patients who show disease progression after failure of first-line therapy. Warfarin is administered in patients with advanced cancer for the prevention or treatment of venous thromboembolism. Both erlotinib and warfarin are metabolized in the human liver primarily by the CYP3A4 enzyme system. Thus, erlotinib may inhibit the metabolism of warfarin and clinicians should pay attention to the possible interaction between the two drugs when they are administered concurrently. We report the case of a 50-year-old man who showed changes in the prothrombin time-international normalized ratio (PT-INR) after coadministration of erlotinib and warfarin. (Korean J Med 2011;80:729-733)

증례 : 혈액종양 ; 췌장 신경 내분비종양에서 sunitinib과 고중성지방혈증

유상훈 ( Sang Hoon Yoo ),우인숙 ( In Sook Woo ),정윤화 ( Yun Hwa Jung ),김교희 ( Gyo Hui Kim ),조영윤 ( Young Yun Cho ),한치화 ( Chi Wha Han ) 대한내과학회 2015 대한내과학회지 Vol.88 No.1

Sunitinib은 multi-target tyrosine kinase 억제제로 현재 위장관 기질종양, 신장암, 췌장 내분비종양에 사용되고 있는 항종양 표적치료제 중의 하나이다. 복용 후 흔하게 호소하는부작용으로는 설사, 피로감, 구역, 구내염, 식도염, 고혈압,피부독성, 갑상선 기능 저하 등이 있다. 또한 급성비결석성담낭염, 알레르기성 간질성신염 같은 드문 부작용이 발생하였다는 보고가 있었으나 고중성지방혈증을 유발한다는 보고는 없었다. 저자들은 전이성 췌장 내분비종양 환자에서 sunitinib투여 후 고중성지방혈증이 관찰되었으며 급성췌장염도동반되었을 것으로 의심되는 증례를 경험하여 기술하였다. 정확한 기전은 아직 밝혀지지 않았지만, 저자들은 본 증례에서 sunitinib이 혈당조절 기전에 영향을 미쳤고, 환자가 췌장미부 절제술을 시행 받아 인슐린 분비능이 감소하였으며, 이로 인해 이차적으로 고중성지방혈증이 발생된 것으로 추정하였다. 또한 sunitinib 투여 후 발생한 갑상선 기능 저하증도고중성지방혈증에 연관되었을 것으로 추정하였다. Sunitinib을 비롯한 multi-target tyrosine kinase 억제제의 임상적 사용이 확대됨에 따라 새로운 부작용들이 보고되고 있으므로 고중성지방혈증을 포함하여 새롭게 발생하는 부작용들의 기전을 밝힐 수 있는 연구들이 시행되어야 하며, 부작용들을 초기에 인지하고 적절히 대처할 수 있도록 주기적인 경과 관찰이 필요하다. Sunitinib is a multi-target tyrosine kinase inhibitor used to treat gastrointestinal stromal tumors, renal cell carcinoma, and pancreaticneuroendocrine tumors. The most common adverse reactions are known to be nausea, fatigue, diarrhea, stomatitis, esophagitis,hypertension, skin toxicity (hand-foot syndrome), hypothyroidism, and reduction in the cardiac output of the left ventricle. Herein,we report the case of a 57 year-old female who visited our hospital complaining of epigastric pain. She had been taking sunitinib at25 mg/day to treat a metastatic pancreatic neuroendocrine tumor. Upon computed tomography performed on admission, we observedthat fluid had collected around the pancreas. Laboratory analysis revealed hypertriglyceridemia (triglycerides 993 mg/dL). Tyrosine kinase inhibitors are known to have limited effects on lipid metabolism. In this case, we suggest that hyperglycemia seemsto have had a limited effect on lipid levels. We are rather of the view that hyperglycemia, a history of distal pancreatectomy, and hypothyrodisim,indirectly caused the observed hypertriglyceridemia.

급성 임파구성 백혈병의 치유를 위한 동종골수이식

이종욱(Jong Wook Lee),김동욱(Dong Wook Kim),한치화(Chi Hwa Han),홍영선(Young Seon Hong),박종원(Chong Won Park),김춘추(Choon Choo Kim),김동집(Dong Jip Kim),김학기(Hack Ki Kim),한경자(Kyung Ja Han),김원일(Won Il Kim) 대한내과학회 1989 대한내과학회지 Vol.36 No.3

N/A Although half of the cases of acute lymphocytic leukemia (ALL) in children have been cured by chemotherapy alone, a dilemma still remains as to the choice of the appropriate therapeutic regimens for childhood ALL in relapse and adult ALL. Recently, 10 patients with ALL were given a supralethal dose of cytoreductive chemoradiotherapy followed by HLA-identical bone marrow transplantation. Among them, only one patient who had been refractory to conventional intensive chemotherapy died of acute renal failure, possibly due to toxicities of the drugs, including long term use of amphotericin-B as well as cyclosporin-A before complete recovery of pancytopenia. Nine patients are enjoying complete remission ranging from 3 to 68 months (median 12 months). Even if the observation period seems to be limited, there were no deaths due to venoocclusive, disease, graft failure, graft versus host reaction, interstitial pneumonia and/or relapse. The actuarial two year disease free survival is 90%. There is still controversy as to determination of the correct 'Timing' for allogeneic bone marrow transplantation in ALL. But we would like to recommend allogeneic bone marrow transplantation for patients with childhood ALL in the advanced state as well as for even minimal residual disease among poor risk groups.