Clostridium difficile 연관 설사에 대한 metronidazole의 치료효과

정혜숙 ( Hae Suk Cheong ),김종규 ( Jong Kyu Kim ),임태규 ( Tae Kyu Lim ),권기태 ( Ki Tae Kwon ),류성열 ( Seong Yeol Ryu ),허상택 ( Sang Taek Heo ),고관수 ( Kwan Soo Ko ),오원섭 ( Won Sup Oh ),백경란 ( Kyong Ran Peck ),이남용 ( Nam 대한내과학회 2007 대한내과학회지 Vol.72 No.6

목적: 본 연구는 국내에서 CDAD에 대한 메트로니다졸 초치료의 치료효과를 조사하고, CDAD의 치료실패 및 재발에 관련된 위험인자를 분석하고자 하였다. 방법: 2000년 1월 1일부터 2005년 5월 31일까지 대변 검사상 C. difficile toxin A 양성인 15세 이상의 성인 환자를 대상으로 의무기록 및 검사결과를 후향적으로 분석하였다. 결과: 총 476예가 연구에 포함되었고, 대상환자의 평균나이는 56.7세였으며 남녀간의 차이는 보이지 않았다. 이 중에서 382예(80.3%)는 초치료로 메트로니다졸을 사용하였고, 9예(1.9%)는 반코마이신을 사용하였다. 메트로니다졸 초치료군 382예 중에서 316예(82.7%)는 치료성공, 29예(6.3%)는 치료실패 그리고 37예(9.7%)는 재발을 보였고, 이러한 치료성공률은 발생연도에 따라서 통계학적으로 유의한 차이를 보이지 않았다. 그리고 경관영양, 이전에 퀴놀론계 항생제의 사용 및 설사횟수가 메트로니다졸 초치료에 대한 치료실패에 유의한 연관성이 있는 것으로 나타났다. 결론: 서구의 경우와는 달리 본원에서 CDAD의 치료에 있어서 메트로니다졸이 아직까지 효과적이지만 이에 대한 지속적인 감시가 필요할 것으로 사료된다. 또한 경관유동, 이전에 퀴놀론계 항생제의 사용, 설사횟수가 많을수록 CDAD에 대한 메트로니다졸 초치료의 치료실패율이 높아진다. Background: The rate of treatment failure with metronidazole for C. difficile-associated diarrhea (CDAD) has been recently increasing in Western countries. A retrospective study was performed to evaluate the clinical outcome of metronidazole treatment and determine the risk factors for treatment failure for patients with CDAD in Korea. Methods: From January 2000 to May 2005, patients who had shown a positive result for C. difficile toxin A assay in feces were considered for the study. Patients who had diarrhea and one or more symptoms of fever, abdominal pain or leukocytosis after 48 hours of hospitalization were included. The medical records of the patients and laboratory data were reviewed. Results: A total of 476 patients (mean age, 56.7 years old) were enrolled in the study. Of these, 382 patients (80.3%) were treated with metronidazole as an initial regimen for CDAD; 316 patients (82.7%) received successful treatment within 14 days, 29 patients (6.3%) had persistent symptoms and signs of colitis and 37 patients (9.7%) had a recurrence of symptoms and signs within 4 weeks after completion of treatment. There were no significant differences in the rates of treatment success for each 5-year period (p>0.05). Among 66 patients who failed to respond to an initial course of metronidazole, 48 patients underwent prolonged or additional courses of metronidazole treatment. Of these, 34 patients (70.8%) were successfully treated. By multivariate analysis, severe diarrhea (p=0.02), prior use of fluroquinolones (p=0.02) and enteral tube feeding (p=0.02) were the risk factors for treatment failure of CDAD with metronidazole. Conclusions: Contrary to a recent survey in Western countries, metronidazole is still useful as a primary regimen for the treatment of patients with CDAD in our institution. In CDAD patients with tube feeding, severe diarrhea or the prior use of quinolones, precautions for treatment failure should be taken. (Korean J Med 72:639-646, 2007)

증례 : p24항원 및 HIV RNA 검사로 진단한 급성 인간면역부전바이러스 감염증 1예

정혜숙 ( Hae Suk Cheong ),오원섭 ( Won Sup Oh ),류성열 ( Seong Yeol Ryu ),허상택 ( Sang Taek Heo ),권기태 ( Ki Tae Kwon ),백경란 ( Kyong Ran Peck ),송재훈 ( Jae Hoon Song ) 대한내과학회 2006 대한내과학회지 Vol.71 No.1S

증례 : 난소에 전이된 원발성 간세포암 1예

임태규 ( Tae Kyu Lim ),엄지은 ( Ji Eun Uhm ),신준암 ( Jun Am Shin ),정혜숙 ( Hae Suk Cheong ),장은희 ( Eun Hee Jang ),박철근 ( Cheol Keun Park ),박준오 ( Joon Oh Park ) 대한내과학회 2006 대한내과학회지 Vol.71 No.5

원발성 간세포암이 난소에 전이하는 경우는 드물다. 이에 저자들은 간세포암 진단을 받고 경간동맥 항암화학 색전술 및 고주파 열치료를 시행받았던 환자에서 간 내에 간세포암의 재발을 보이지는 않았으나 지속적인 알파태아단백 상승이 있던 중 난소에서 발견된 전이성 간세포암 1예를 경험하였기에 문헌고찰과 함께 보고하는 바이다. Primary hepatocellular carcinoma with metastasis to the ovary is a rare malady. To the best of our knowledge, approximately eight cases in the English literature and two cases in the Korean literature have been reported. We report here a case of hepatocellular carcinoma with metastasis to the ovary in a 40-year-old woman who presented with a month long history of lower abdominal discomfort and a palpable mass. She had been diagnosed with hepatocellular carcinoma (HCC) four years prior and subsequently underwent a several courses of transarterial chemoembolization and radio-frequency ablation. The patient had then been seen regularly and was generally well until 4 month ago, when the alpha fetoprotein (AFP) level began to rise to 425 ng/mL. After that time she had been seen and examined every month, however, the AFP level rose to 2,150 ng/mL without evidence of recurrence on the computed tomography (CT) scan of liver, the heapatic artery angiography, PET and so on. On admission, a pelvis MRI revealed mainly solid masses of both ovaries and multiple peritoneal and omental nodules. Transvaginal core biopsy was performed and the histologic examination of the specimen revealed metastatic hepatocellular carcinoma. We report here on one case of ovarian metastasis from hepatocellular carcinoma together with a brief review of the literature.(Korean J Med 71:573-576, 2006)

증례 : 흉선암과 동반된 Sweet 증후군 1예

김종규 ( Jong Kyu Kim ),양정훈 ( Jeong Hoon Yang ),엄지은 ( Ji Eun Uhm ),정혜숙 ( Hae Suk Cheong ),이동윤 ( Dong Youn Lee ),장기택 ( Kee Teak Jang ),박준오 ( Joon Oh Park ) 대한내과학회 2007 대한내과학회지 Vol.72 No.1S

펜타미딘으로 치료 받은 후천성 면역 결핍증 환자에서 발생한 저혈당 1예

송기호 ( Kee Ho Song ),황용 ( Yong Hwang ),최홍석 ( Hong Seok Choi ),기현균 ( Hyun Kyun Ki ),정혜숙 ( Hae Suk Cheong ),서정웅 ( Jung Woong Seo ),정현아 ( Hyun Ah Chung ) 대한내과학회 2012 대한내과학회지 Vol.83 No.5

Trimethoprim-sulfamethoxazole (TMX-SMZ) is the initial treatment for Pneumocystis jiroveci pneumonia in human immunodeficiency virus (HIV) patients. About 20% of patients do not complete the TMX-SMZ treatment due to treatment failure or adverse reactions. Pentamidine isethionate has been used for P. jiroveci pneumonia as a second-line regimen. Although hypoglycemia is a common adverse effect of pentamidine, pentamidine-induced hypoglycemia has not been reported in Korea. We present an HIV patient with grand mal seizures caused by pentamidine-induced hypoglycemia who was managed successfully with IV dextrose infusion. Mental changes can occur during pentamidine treatment, but hypoglycemia is often ignored and misdiagnosed as epilepsy or stroke. It can result in seizures, coma, and even death. We should be aware of pentamidine-induced hypoglycemia, which can lead to severe neurologic deficits and diabetes mellitus. (Korean J Med 2012;83:679-682)

황색포도알균에 의한 감염성 심내막염의 임상적 특성

백경란 ( Kyong Ran Peck ),송재훈 ( Jae Hoon Song ),김은석 ( Eun Seok Kim ),주은정 ( Eun Jeong Joo ),하영은 ( Young Eun Ha ),위유미 ( Yu Mi Wi ),정혜숙 ( Hae Suk Cheong ),이진서 ( Jin Seo Lee ),강철인 ( Cheol In Kang ),정두련 ( Doo 대한내과학회 2009 대한내과학회지 Vol.76 No.3

Background/Aims: The risk factors and clinical outcome of infective endocarditis (IE) have changed over the past few decades. Recently, the incidence of Staphylococcus aureus IE (SAIE) has increased. We investigated the clinical and microbiological characteristics and clinical outcomes of SAIE. Methods: All patient cases that were diagnosed as IE according to the modified Duke criteria in Samsung Medical Center during the period of January 1995 to December 2006 were reviewed retrospectively. The clinical and microbiological characteristics of patients with SAIE were compared to those of non-SAIE patients with IE. Results: We enrolled 304 patients with IE. Of these, 240 cases were IE culture-positive, including 73 cases of SAIE. The mean age of patients with SAIE was 48.15±19.87 years, with male patients accounting for 71.2% of our study group. Congenital heart disease (8.2%) was less common among SAIE patients. Hospital-acquired IE was significantly more common in SAIE than in non-SAIE cohorts (p<0.05). Surgical treatment was performed in 33 cases (45.2%). Valvular regurgitation with heart failure was the most frequent cause of surgery (39.3%). Twenty-three cases exhibited complications, including extra cardiac embolization (16.4%) and heart failure (5.6%). Fever persisting for a period longer than seven days was more common among those in the SAIE group. Twelve patients (16.4%) died and four patients (5.4%) were discharged without hope of improvement. The in-hospital mortality rate was higher among SAIE patients (17.3%) compared to that among non-SAIE patients (11%), although this comparison was not statistically distinct (p>0.05). Methicillin resistance and non-surgical treatment were significant risk factors for in-hospital mortality. Conclusions: SAIE is more strongly associated with systemic embolization, persistent fever, and longer hospital stays compared to non-SAIE. Further studies are warranted to evaluate adequate treatment and to improve the outcome of patients with SAIE. (Korean J Med 76:329-337, 2009)

결핵성 수막염 진단을 위한 지표의 타당성 평가

정동식 ( Dong Sik Jung ),오유정 ( You Jeong Oh ),권기태 ( Ki Tae Kwon ),이지영 ( Ji Young Rhee ),신상엽 ( Sang Yop Shin ),정혜숙 ( Hae Suk Cheong ),이남용 ( Nam Yong Lee ),이혁 ( Hyuck Lee ),정두련 ( Doo Ryeon Chung ),백경란 ( Ky 대한내과학회 2008 대한내과학회지 Vol.75 No.3

목적: 결핵성 수막염은 중추신경계 감염 중 가장 흔한 질환 중의 하나이며 조기 진단과 치료가 되지 않을 경우 20~50%의 사망률과 높은 신경학적 합병증을 초래한다. 본 연구는 간단한 임상양상과 검사실 소견만으로 결핵성 수막염을 조기 진단하는데 도움을 주는 것으로 알려진 Thwaites 등이 제안한 진단지표를 국내에서도 유용하게 활용할 수 있는지를 평가하고자 하였다. 방법: 1995년 3월부터 2005년 12월까지 10년 동안 삼성서울병원 응급실에 수막염을 시사하는 임상소견을 가지고 내원한 환자 중 뇌척수액에서 결핵균이 나오거나 결핵균 중합효소연쇄반응 양성이 나온 결핵성 수막염 환자와 뇌척수액에 세균이 나오거나 혈액배양에서 세균이 동정되었으나 수막염 외에는 다른 감염 병소가 없는 급성 세균성 수막염 환자를 대상으로 진단지표의 타당성을 후향적으로 조사하였다. 결과: 총 77명의 환자가 본 연구에 포함되었으며 이 중 47명이 결핵성 수막염, 30명이 급성 세균성 수막염이었다. 결핵성 수막염 47예 중 이 진단지표(Thwaites등이 제안한 최적 결정치 4이하)를 통해 47명 모두(100%)가 진단이 가능했고, 세균성 수막염 30예 중 27예(90%)가 진단이 가능했다. 본 연구에서는 Area under ROC curve는 0.993 (95% CI, 0.979-1.0)으로 진단적 정확도가 높게 나왔으며 최적 결정치는 지표의 총합이 3이하인 경우 민감도와 특이도의 합이 최대로 나왔다. 그에 따른 민감도 100%, 특이도 93.3%, 양성예측도 95.9%, 음성예측도 100%이었다. 결론: 임상양상과 검사실 소견으로 결핵성 수막염과 급성 세균성 수막염을 감별진단 하는 Thwaites의 진단지표는 국내에서도 진단적 타당도가 높아 유용하게 활용 가능할 것으로 기대된다. 또한 최적 결정치는 지표의 총합이 3이하인 경우가 진단적 타당도가 더 높은 결과를 보였다. Background/Aims: Tuberculous meningitis is a common, occasionally fatal infectious disease of the central nervous system. We evaluated the diagnostic validity of weighted diagnostic index scores (WDIS), which have been suggested to aid in the diagnosis of adult patients with tuberculous meningitis, on the basis of simple clinical and laboratory findings. Methods: The microbiological and clinical data of adult patients with either tuberculous or bacterial meningitis were reviewed retrospectively. Diagnostic validity and WDIS cut-off values were evaluated by receiver operating characteristic (ROC) curve analysis. Results: A total of 77 cases were included: 47 with tuberculous meningitis and 30 with bacterial meningitis. For the diagnosis of tuberculous meningitis, the sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of WDIS suggested by Thwaites (cut-off value of ≤4) were 100, 90, 94 and 100%, respectively. Based on ROC curve analysis (area under ROC curve=0.993), a cut-off value of ≤3 was most appropriate for the diagnosis of tuberculous meningitis. The sensitivity and specificity of WDIS with a cut-off value of ≤3 were 100 and 93.3%, respectively. Conclusions: Our study demonstrated that WDIS are highly predictable and acceptable for the early diagnosis of tuberculous meningitis in Korea, based on our analysis of clinical and laboratory findings. A cut-off value of ≤3 showed the best diagnostic validity. (Korean J Med 75:316-321, 2008)

동종 조혈 모세포 이식 환자에서 감염증의 양상에 대한 고찰

이지영 ( Ji Young Rhee ),장은희 ( Eun Hee Jang ),김승태 ( Seung Tai Kim ),위유미 ( Yu Mi Wi ),손경목 ( Kyong Mok Son ),정혜숙 ( Hae Suk Cheong ),기현균 ( Hyun Kyun Ki ),오원섭 ( Won Sup Oh ),김기현 ( Ki Hyun Kim ),정철원 ( Chul Wo 대한내과학회 2007 대한내과학회지 Vol.72 No.2

목적: 조혈 모세포 이식을 받은 환자의 감염증의 양상을 분석하고, 감염증이 사망률에 미치는 영향과 사망률에 대한 위험인자의 예측 근거를 제시 하고자 한다. 방법: 1996년 2월에서 2003년 10월까지 본원에서 동종 조혈 모세포 이식을 받은 환자를 대상으로 후향적으로 조사하였다. 결과: 총 139명의 환자들이 조혈 모세포 이식을 시행 받았으며, 연령의 중앙값은 33.9세였고 추적관찰기간의 중앙값은 18.8개월이었으며, 감염성 합병증의 평균 발생빈도는 3.24±3.00회/인이었다. 총 450회의 감염증이 관찰되었고, 이 중 미생물학적으로 확인된 감염이 41.6%였으며 임상적으로 확인된 감염증은 34.0%, 불명열이 24.4%를 차지하였다. 감염성 합병증은 대부분 조기 회복기에 발생하였으며 전체의 39.6%가 이 시기에 발생하였고, 만기 회복기, 중간 회복기 순으로 각각 32.4%, 24.4%를 차지하였다. 미생물학적으로 확인된 감염의 187개의 사례 중에 세균감염이 94회였고, Coagulase-negative staphylococci가 15회로 가장 많이 분리되는 균종이었다. 미생물학적으로 확인된 감염 중 바이러스 감염은 78회로 41.7%를 차지하였으며, CMV감염증이 가장 많았다. 진균의 경우 전체 미생물학적으로 확인된 감염 중 7.5%를 차지하였으며, 이 중 Aspergillus spp.가 가장 많았다. 감염과 연관되어 사망한자 19명 중 12명(63.2%)이 만기회복기에 발생하였다. 감염성 사망률에 대한 위험요인으로는 기저 질환의 위험도, 호중구 감소 기간, 조혈 모세포 생착 실패, 급성/만성 이식 편대 숙주 반응등이 통계적으로 유의하게 나왔다(p<0.05). 결론: 급성/만성 이식 편대 숙주 반응과 연관하여 높은 감염성 사망률을 보였으며, 이는 특히 후기 감염과 연관된다. 또한, 진균감염 특히, candida 감염증의 빈도가 낮은 병원에서는 fluconazole 예방적 사용의 임상적 효과는 분명치 않다. Background: We wanted to investigate the effect of infectious complications on the outcome of patients who received allogeneic hematopoietic stem cell transplantation (HSCT), and we determined the risk factors for predicting infectious complication and the mortality in allogeneic HSCT recipients. Methods: We enrolled all the patients who underwent allogeneic HSCT at Samsung Medical Center from February 1996 to October 2003. Results: A total of 139 patients were enrolled. A total of 450 infectious episodes were observed in 131 allogeneic recipients (90.8%). Infectious complications occurred in the allogeneic recipients [3.243.00 episodes/patient]. Microbiologically documented infection (MDI), clinically documented infection (CDI), and unknown fever (UF) accounted for 41.6%, 34.0% and 24.4%, respectively, of the total infections. Pneumonia (15.1%) was the most common infection. Among the 187 MDIs, bacterial infection, viral infection and fungal infection accounted for 50.3%, 39.6%, and 7.5%, respectively. Twelve of 24 deaths in the late post-transplantation period were related with infection. The statistically significant risk factors for infection related to mortality, by multivariate analysis, were the underlying disease risk, the duration of neutropenia, the failure of stem cell engraftment, acute GVHD, MDI, UF, the number of infectious episodes, bacteremia, fungemia, pneumonia, genitourinary tract infections, S. aureus, E. coli, Pseudomonas spp., Aspergillus spp., Non-albicans candida and CMV diseases. Conclusions: The incidence of fungal infections was still low in our institute, even though prophylaxis for fungal infections was not applied, except for gargling with nystatin. In addition, most of them were non-albican Candida and Aspergillus species. Therefore, routine fluconazole prophylaxis may not be needed in our institute. (Korean J Med 72:200-208, 2007)