식물 제제와 연관된 급성 독성 간염으로 인한 간이식 : 원인 제제와 손상 유형에 대한 후향적 분석

손창환,차명일,오범진,여운형,이재호,김원,임경수,Sohn, Chang-Hwan,Cha, Myung-Il,Oh, Bum-Jin,Yeo, Woon-Hyung,Lee, Jae-Ho,Kim, Won,Lim, Kyoung-Soo 대한임상독성학회 2008 대한임상독성학회지 Vol.6 No.2

Purpose: Acute toxic hepatitis is a common cause of acute liver failure (ALF). We investigated the causes, clinical manifestation, and outcomes of ALF patients who underwent liver transplantation due to acute toxic hepatitis caused by herbal medicines and preparations. Methods: Between January 1992 and May 2008, we retrospectively reviewed the medical records of 24 patients who were transplanted due to acute toxic hepatitis caused by herbal medicines and preparations. We applied the RUCAM score to patients with acute toxic hepatitis and assessed the relationship between herbal preparations and liver injury. We studied the patients' medication history, liver function tests, and clinical outcomes. Results: The type of liver injury was divided into three groups: hepatocellular type, 14 patients (58.3%); cholestatic type, 4 patients (16.7%); and mixed type, 6 patients (25%). Polygonum multiflorum Thunberg (3 cases) was the most common cause of acute toxic hepatitis, followed by Acanthopanax senticosus (2 cases), pumpkin juice (2 cases), Dictamnus dasycarpus Turcz (2 cases), Hovenia dulcis (1 case), Phellinus linteus (1 case), and Artemisia capillaries (1 case). One year survival after liver transplantation was 76%. Conclusion: We identified the herbal preparations leading to acute liver failure. Many patients consider herbal remedies to be completely free of unwanted side effects. However, we found that many herbal products have biological activities that can lead to severe hepatotoxicity.

복어 중독의 임상적 분석

현승환 ( Seung Hwan Hyun ),손창환 ( Chang Hwan Sohn ),유승목 ( Seung Mok Ryoo ),오범진 ( Bum Jin Oh ),임경수 ( Kyung Soo Lim ) 대한임상독성학회 2011 대한임상독성학회지 Vol.9 No.2

Purpose: Ingestion of puffer fish can be poisonous due to the presence of potent neurotoxins such as tetrodotoxin (TTX) found in its tissues. There are few clinical reports related to TTX. We performed this study to evaluate the clinical characteristics of TTX poisoning. Methods: We conducted a retrospective study of the 41 patients diagnosed with TTX poisoning who visited the Seoul Asan medical center from July 2004 and December 2010. A review of patients’electronic medical records and patient telephone interviews were conducted. Diagnosis of TTX poisoning was confirmed by observing the casual link between puffer fish consumption and the development of typical TTX intoxication symptoms. Results: The mean age of the patients included in the study was 46.6 years. The highest incidence of intoxication was observed in patients in their 50s (10 patients). Seasonal distribution of intoxication events included 10 in spring, 7 in summer, 10 in fall, and 14 in winter. In most cases, symptoms occurred within 1 hour of ingestion. A wide range of symptoms were associated with puffer fish ingestion affecting multiple body systems including neuromuscular (27 patients), gastrointestinal (19 patients), and cardiopulmonary/vascular (19 patients). All patients were treated with symptomatic and supportive therapy and recovered completely, without sequelae, within 48 hours. In three cases, ventilator support was required. Conclusion: TTX poisoning is not seasonally related, and patients admitted to the emergency room were observed with a wide range of symptoms. Where TTX poisoning is diagnosed, supportive therapy should be performed. Early intubation and ventilation is important, especially is cases of respiratory failure.

와파린 항응고 유지요법 중 발생한 급성출혈의 임상소견과 사망관련 인자

이세호,김남규,손창환,김중헌,김원,임경수,오범진,Lee, Se-Ho,Kim, Nam-Kyu,Sohn, Chang-Hwan,Kim, Jung-Hun,Kim, Won,Lim, Kyung-Soo,Oh, Bum-Jin 대한임상독성학회 2009 대한임상독성학회지 Vol.7 No.2

Purpose: The number of patients who take warfarin is growing and so is the number of complications. Hemorrhage is the major complication, but the clinical characteristics and outcomes have not been determined for Korean patients. Therefore, we tried to evaluate the characteristics of the patients with hemorrhagic complications after taking warfarin as anticoagulation therapy. Methods: We retrospectively reviewed the medical records of the patients who visited the emergency room with bleeding complications after taking warfarin anticoagulation at the out-patient clinic for 1 year from 1 st January 2008. We compared between two groups (the major hemorrhage group vs. the minor hemorrhage group) according to the clinical criteria, the unstable vital signs that required blood transfusion, transfusion more than 2 units of blood, the need for further laboratory follow-up, the need for interventional treatment and the development of critical complications or death due to bleeding. Results: There were 150 patients who met the criteria and had acute hemorrhagic complications (the major group: 90 patients and the minor group: 60 patients). In the major hemorrhage group, the frequent sites of bleeding were the gastro-intestinal system (40 patients), lung (14 patients) and intracranium (7 patients). At the emergency room, the major group showed a higher initial INR of the activated prothrombin time than did the minor group (p=0.02). The bleeding sites of the fatal cases were the gastro-intestinal system (3 patients), lung (3 patients) and intracranium (3 patients), but the percentage of fatality was the highest for intracranium bleeding. Conclusion: In the major hemorrhage group, gastrointestinal bleeding was the most frequent complication and fatality was the highest for intracranium bleeding. An initially higher INR showed a greater risk of major bleeding, but not more fatalities.

고연령 안와파열 골절 환자의 수상 원인과 컴퓨터 단층촬영 소견 및 동반 골절의 연령별 비교

서동우 ( Dong Woo Seo ),손창환 ( Chang Hwan Sohn ),정상구 ( Sang Ku Jung ),안신 ( Shin Ahn ),김원영 ( Won Young Kim ),김원 ( Won Kim ) 대한외상학회 2009 大韓外傷學會誌 Vol.22 No.1

Purpose: The purpose of this study was to evaluate the causes of blow-out fractures, the computed tomography findings, and the associated facial bone fractures in aged patients. Methods: This study was performed by conducting a chart review. From January 2004 to December 2007, the patients who visited the emergency room of Asan Medical Center and were diagnosed as having a blow-out fracture were included in the study population. Patients 60 years of age or older were grouped as the aged group while patients younger than 60 years of age were grouped as the control group. Results: Between the aged group and the control group, there was a difference in the causes of blow-out fractures. The most common cause of blow-out fracture was a slip down in the aged group and violence in the control group (p<0.05). There were no differences in associated symptoms. Extraocular muscle herniation was the only statistically different computed tomography findings. In associated facial bone fractures, the most common fractures were the zygoma in the aged group and the nasal bone in the control group (p<0.05). Conclusion: In patients 60 years of age or older, the most common cause of blow-out fracture was a slip down, and the most common associated facial bone fracture was a zygomatic fracture. (J Korean Soc Traumatol 2009;22:44-50)

두 가지 항부정맥 약제를 병용 투여하여 성공적으로 치료한 심실빈맥이 동반된 부자중독 1례 보고

유승목 ( Seung Mok Ryoo ),손창환 ( Chang Hwan Sohn ),오범진 ( Bum Jin Oh ),김원 ( Won Kim ),임경수 ( Kyoung Soo Lim ) 대한임상독성학회 2011 대한임상독성학회지 Vol.9 No.2

Aconitine is an anti-inflammatory agent with therapeutic uses in oriental medicine as an analgesic and for treatment of stroke. Because of its sodium channel effect, aconitine can promote undesirable, wide complex tachyarrhythmia. If tachycardia develops during use of aconitine, class Ia and class III anti arrhythmic drugs can be utilized for treatment. However there are no single anti-arrhythmia agents which are uniformly effective. We report a case, characterized by wide complex tachyarrhythmia and severe hypotension, which was successfully treated by simultaneous injections of amiodarone and lidocaine. A 59-year-old woman exhibiting clinical signs of drowsiness as a result of ingesting 6 g of aconitine, was admitted to the emergency department. Initially, wide complex tachyarrhythmia (ventricular tachycardia and pulse rate of 180 beats/min) and severe hypotension (blood pressure of 53/26 mmHg) was observed. After simultaneous injection of amiodarone and lidocaine, the patient’s rhythm pattern changed to an accelerated junctional rhythm with ventricular premature complex. Two hours later, the patient’s heart pattern became a sinus rhythm. As demonstrated by this case, simultaneous injections of amiodarone and lidocaine can be useful in treating ventricular arrhythmia induced by aconitine.

증례 : 호흡기 ; 수은 증기에 의한 급성 폐손상 1예

권병수 ( Byoung Soo Kwon ),허진영 ( Jin Young Huh ),김준환 ( Jun Hwan Kim ),손창환 ( Chang Hwan Sohn ),채은진 ( Eun Jin Chae ),송진우 ( Jin Woo Song ) 대한내과학회 2015 대한내과학회지 Vol.89 No.5

다른 기저질환이 없는 환자에서 원인 미상의 급성 폐손상이 발생할 경우 신체 진찰뿐만 아니라 철저한 병력 청취가 중요하다. 저자들은 급성 폐손상으로 내원한 환자에게 원인 규명을 위한 검사에서 수은 중독으로 판단하고 적절한 치료를 통하여 호전된 것을 경험하였기에 문헌고찰과 함께 보고하는 바이다. Mercury is traditionally used as a dye for making amulets in Korea. Inhaling the vapor produced by burning mercury damages major organs, such as the lungs, kidneys, and brain. We herein present a case of a 41-year-old man who complained of abdominal pain and dyspnea. A chest X-ray and computed tomography scan showed infiltration in both upper lung lobes. A thorough medical history revealed that the patient had made amulets prior to developing symptoms, and blood and urine tests confirmed elevated levels of mercury. Dimercaptosuccinic acid was used to chelate the mercury, and methylprednisolone was used to treat the acute lung injury. No kidney or nervous system complications were detected during follow-up. Inhalation of mercury vapor should be suspected in patients with acute lung injury involving both upper lobes. (Korean J Med 2015,89:563-566)

신종인플루엔자 폐렴환자에서 임상적 악화와 연관된 초기 전산화 단층촬영 소견

유승목 ( Seung Mok Ryoo ),김원영 ( Won Young Kim ),이충욱 ( Choong Wook Lee ),손창환 ( Chang Hwan Sohn ),서동우 ( Dong Woo Seo ),이윤선 ( Yoon Seon Lee ),이재호 ( Jae ho Lee ),오범진 ( Bum Jin Oh ),김원 ( Won Kim ),임경수 ( Kyoun 대한결핵 및 호흡기학회 2010 Tuberculosis and Respiratory Diseases Vol.69 No.2

Background: The aim of the present study was to evaluate whether findings on initial chest computed tomography (CT) of influenza pneumonia can help predict clinical outcome. Methods: We reviewed all adult patients admitted to the Emergency Department (ED) with a confirmed diagnosis of novel influenza A H1N1 virus (2009 H1N1) pneumonia, who underwent chest CT upon admission between Aug 26, 2009 and Jan 31, 2010. Radiologic findings were characterized by type and pattern of opacities and zonal distribution. Clinical outcome measures were intensive care unit (ICU) admission, mechanical ventilation, and inhospital death. Results: Of 59 patients diagnosed with 2009 H1N1 pneumonia, 41 (69.5%) underwent chest CT on admission into ED. Nine (22%) of these patients developed adverse clinical outcomes requiring the following treatments: 9 (22.0%) ICU admissions, 5 (12.2%) mechanical ventilation, and 3 (7.3%) inhospital deaths. Counting the number of patients with more than 4 involved lobes, the sensitivity, specificity, positive predictive value, and negative predictive value for detection of adverse clinical outcome were 67%, 84%, 55% and 80%, respectively. Conclusion: Extensive involvement of both lungs (over 4 lobes) is related to ICU admission, mechanical ventilation, and inhospital death. Initial chest CT may help predict an adverse clinical outcome of patients with 2009 H1N1 influenza pneumonia.

2009 H1N1 인플루엔자 폐렴에서 Procalcitonin의 유용성: 세균성 폐렴과의 감별 역할

안신 ( Shin Ahn ),김원영 ( Won Young Kim ),윤지영 ( Ji Young Yoon ),손창환 ( Chang Hwan Sohn ),서동우 ( Dong Woo Seo ),김성한 ( Sung Han Kim ),홍상범 ( Sang Bum Hong ),임채만 ( Chae Man Lim ),고윤석 ( Youn Suck Koh ),김원 ( Won 대한결핵 및 호흡기학회 2010 Tuberculosis and Respiratory Diseases Vol.68 No.4

Background: Procalcitonin is a well known marker in infection that plays a role in distinguishing between bacterial and viral infections in screening. The aim of the present study was to evaluate the role of procalcitonin in differentiating between 2009 H1N1 influenza pneumonia and community acquired pneumonia of bacterial origin, or mixed bacterial origin and 2009 H1N1 influenza infection. Methods: A retrospective observational study was performed over the 6-month winter period during the 2009 H1N1 influenza pandemic. Ninety-six patient-subjects were enrolled, all of whom had been diagnosed with community acquired pneumonia in emergency department during the study period. On admission, laboratory studies were performed, which included 2009 H1N1 influenza real-time polymerase chain reaction of nasal secretions and procalcitonin on serum; the laboratory values were compared between the study groups. Receiver operating characteristic curve analyses were performed on the resulting data. Results: Compared to those with bacterial or mixed infections (n=62) and bacterial pneumonia with confirmed organisms (n=30), patients with 2009 H1N1 pneumonia (n=34) were significantly more likely to have low procalcitonin levels (p=0.008, 0.001). Using cutoff of value >0.3 ng/mL, the sensitivity and specificity of procalcitonin for detection of patients with confirmed bacterial pneumonia were 76.2% and 60.6%, respectively. A significant difference in procalcitonin was found between 2009 H1N1 pneumonia and pneumonia caused by mixed influenza viral and bacterial infections (0.15 [0.05∼0.84] vs. 10.3 [0.05∼22.87] ng/mL, p=0.045). Conclusion: Serum procalcitonin measurement may assist in the discrimination between pneumonia of bacterial and of 2009 H1N1 influenza origin. High values of procalcitonin suggest that bacterial infection or mixed infection of bacteria and 2009 H1N1 influenza is more likely.

독극물정보센터 구축사업의 일환으로 시행한 전국단위 응급해독제 비축 및 배송경험

박소영 ( So Young Park ),오범진 ( Bum Jin Oh ),손창환 ( Chang Hwan Sohn ),정루비 ( Ru Bi Jeong ),임경수 ( Kyoung Soo Lim ),김원 ( Won Kim ),유승목 ( Seung Mok Ryoo ) 대한임상독성학회 2013 대한임상독성학회지 Vol.11 No.1

Purpose: Antidotes for toxicological emergencies can be life-saving. However, there is no nationwide stocking and delivery system for emergency antidotes in Korea. We report on a two-year experience of a nationwide stocking and delivery trial for emergency antidotes at emergency departments in Korea. Methods: An expert panel of clinical toxicologists reviewed and made a list of 15 stocked antidote. These antidotes were purchased or imported from other countries and delivered from 14 antidote stocking hospitals nationwide 24 hours per day, seven days per week. Results: From August 1, 2011 to April 30, 2013, 177 patients with acute poisoning, with a median age of 48.5 years, were administered emergency antidotes. The causes of poisoning were intentional in 52.0% and 88.0% were intentional as a suicide attempt. Regarding clinical severity, using the poisoning severity score, 40.7% of patients had severe to fatal poisoning and 39.0% had moderate poisoning according to clinical severity. The most frequent presenting symptom was neurologic deficit, such as altered mentality (62.7%). alerted mentality (62.7%). Emergency antidotes were administered as follows: methylene blue (49 cases), flumazenil (31), N-acetylcysteine (25), glucagon (17), 100% ethanol (15), cyanide antidote kit (12), anti-venin immunoglobulin (5), pyridoxine (4), hydroxocobalamine (2), and deferoxamine (1). The median time interval from antidote request to delivery at the patient’s bedside was 95 minutes (interquartile range 58.8-125.8). Conclusion: Findings of this study demonstrated the possibility of successful operation of the nationwide system of emergency antidotes stocking and delivery in Korea.

정상혈압 폐색전증에서 위험도 평가도구로서의 D-dimer의 역할

윤재철 ( Jae Chol Yoon ),김원영 ( Won Young Kim ),최상식 ( Sang Sik Choi ),정상구 ( Sang Ku Jung ),손창환 ( Chang Hwan Sohn ),김원 ( Won Kim ),임경수 ( Kyoung Soo Lim ),정태오 ( Tae O Jeong ),진영호 ( Young Ho Jin ),이재백 ( Jae 대한결핵 및 호흡기학회 2010 Tuberculosis and Respiratory Diseases Vol.68 No.2

Background: D-dimer testing is widely applied as a first step in the diagnostic work-up of pulmonary embolism (PE). Although this is the most sensitive assay for ruling out PE, the prognostic implications of D-dimer testing in patients with normotensive PE are not well known. The aim of this study was to determine if D-dimer testing on admission predicts major adverse cardiac events (MACE) in patients with normotensive PE. Methods: A total of 180 consecutive patients with normotensive PE admitted between January 2003 and June 2009 were included. The group was divided into quartiles on the basis of their D-dimer levels. We compared the frequency of MACE by quartile of D-dimer level and estimated sensitivity, specificity, and predictive values for MACE in the first and fourth quartile. Results: In the 37 (20.6%) patients with MACEs, the median D-dimer level (7.94 [IQR: 4.03∼18.17] μg/mL) was higher than in patients with a benign course (5.29 [IQR: 2.60∼11.52] μg/mL, p<0.01). The occurrence of MACEs was increased with increasing D-dimer level (p=0.017). In the first quartile (D-Dimer <2.76 μg/mL) sensitivity, specificity, and positive and negative predictive values for predicting MACEs were, respectively, 91.9%, 29.4%, 25.2%, and 93.3%. Conclusion: Patients with D-dimer levels below 2.76 μg/mL have a low risk of MACEs. Our study suggest that D-dimer level may be used to identify low risk patients with normotensive PE.