심포지움 : 병원감염의 치료와 예방

김양리 ( Yang Ree Kim ) 대한내과학회 1999 대한내과학회 추계학술대회 Vol.57 No.-

복강 내 결핵성 농양의 CT 소견과 임상경과

김양리 ( Yang Ree Kim ) 대한내과학회 2008 대한내과학회지 Vol.74 No.3

Paradoxical response during antituberculosis treatment occurs frequently in non-HIV-infected patients as well as in HIV-infected patients, and intraperitoneal tuberculous abscess can develop as paradoxical response in tuberculous peritonitis patients rarely. The unique CT findings are not present and microbiologic or pathologic confirm is needed for diagnosis of intraperitoneal tuberculous abscess. Further study is needed to define steroid use or operation indication of intraperitoneal tuberculosis abscess. (Korean J Med 74:233-234, 2008)

HIV감염과 MICA (MHC class I chain-related A) 대립 유전자의 연관성

강문원,위성헌,김양리,이주실,표철우,한훈,김태규,Kang, Moon-Won,Wie, Seong-Heon,Kim, Yang-Ree,Lee, Joo-Shil,Pyo, Chul-Woo,Han, Hoon,Kim, Tai-Gyu 대한면역학회 2001 Immune Network Vol.1 No.2

Background: A large number of diseases occur in association with specific HLA-B or-C alleles. Recently a new gene, termed maj or histocompatibility complex class I chain-related gene A (MICA), has been identified in close proximity to HLA-B. The function of this gene is still unknown. However, it is structurally similar to HLA class I genes. MICA gene is polymorphic and is potentially associated with several diseases. Methods: To evaluate the association of MICA gene in Korean patients with human immunodeficiency virus 1 (HIV-1) infections, Polymerase chain reaction-Sequence specific primer (PCR-SSP) was done for MICA alleles in the extracellular exons, and a microsatellite analysis for GCT repeat polymorphisms in the TM exon was also completed. Results: In 199 Korean healthy controls, 7 alleles were observed and the frequencies for each allele were MICA008 (44.7%), MICA0 10 (34.2%), MICA002 (31.7%), MICA004 (23.6%), MICA0 12 (2 1.6%), MICA009 (19.6%), and MICA007 (6.5%). When 65 HIV seropositive patients were analyzed, MICA007 allele frequency was significantly higher than in controls (15.4% vs 6.5 %, RR=2.6, p<0.04). In contrast, the frequencies of other MICA alleles and microsatellite alleles in the transmembrane region of MICA gene were not significantly different between HIV seropositive patients and controls. The tight linkage between MICA alleles in the extracellular exons and GCT repeat polymorphisms in the TM exon was observed as follows; MICA002/A9, MICA004/A6, MICA007/A4, MICA008/A5.1, MICA0 10/A5, and MICA0 12/A4 in both groups. No significant difference between patients and controls was observed in the haplotype frequencies of MICA alleles in the extracellular exons and GCT repeat polymorphisms in the TM exon. Conclusion: The data suggest that immune functions related with MICA gene may affect a HIV infections.

A small epidemiological survey for vivax malaria in Kimpo-gun, Kyonggi-do, Korea undertaken after detecting two consecutive cases

Jong-Min LEE(이종민),Mi-Young KIM(김미영),Yang-Ree KIM(김양리),Moon-Won KANG(강문원),Nam-Seok LEE(이남석),Seung-Yull CHO(조승열),Hyeong-Woo LEE(이형우),Won-Ja LEE(이원자),Jong-Soo LEE(이종수) 대한기생충학열대의학회 1997 The Korean Journal of Parasitology Vol.35 No.4

전격성 자반병의 임상 양상을 보인 Streptococcal Toxic Shock Syndrome

권현조 ( Hyun Jo Kwon ),김미연 ( Mi Yeon Kim ),박영민 ( Young Min Park ),김형옥 ( Hyung Ok Kim ),김양리 ( Yang Ree Kim ),강문원 ( Moon Won Kang ) 대한피부과학회 2006 대한피부과학회지 Vol.44 No.3

급성 백혈병 환자에서의 감염양상 - 1981 년 ~ 1984 년과 1987 년 ~ 1991 년의 비교 -

최황(Hwang Choi),유진홍(Jin Hong Yoo),신완식(Wan Shik Shin),김양리(Yang Ree Kim),강문원(Moon Won Kang),김동욱(Dong Wook Kim),이종욱(Jong Wook Lee),박종원(Jong Won Park),김춘추(Choon Choo Kim),김동집(Dong Jip Kim) 대한내과학회 1994 대한내과학회지 Vol.46 No.4

N/A Background: Infection, as a potential life-threatening factor, remains a major concern in the management of patients with acute leukemia, especially whose peripheral neutrophil counts are decreased (below 1000/mm³). The spectrum of infection has been changed by many factors. We observed the changing pattern of the spectrum of infection in patients with acute leukemia according to febrile day, number of leukocyte, infection site, pathogen, and prophylactic use of oral antibiotics for the purpose of reduction in morbidity and mortality by infection. Methods: The spectrum of infection of 200 patients with acute leukemia from January, 1987 to December, 1991 was compared with that of 90 patients from Jsnuary, 1981 to June, 1984 (reported previously). Results: 1) The most common ca of death in patients with acute leukemia was infection, The mortality due to hemorrhage was decreased in group of 1987-1991 and the death from infection was increased, relatively. 2) The more prolonged period of leukopenia was, the longer febrile days were. 3) The most common site of infection during both period was lung (58.0%, 49.6%, respectively). Bacteremia was increased from 7.1% to 20.3%. 4) Microbiologically defined infection was increased in 1987-1991 group (46.9%) compared with 1981-1984 group (17.3%), and the incidence of clinically defined infection was 28.1% in 1981-19S4 group and 35.3% in 1987-1991 group. 5) There was no statistically significant difference in the incidence of organisms causing infection in both group. In 1981-1984 group, it was 37.5% of gram-negative organism and 32.5% of gram-positive organism, and in 1987~1991 group, 40.3%, 39.7%, respectively. Pseudomonas among gram-negative organisms and Staphylococci among gram-positive organisms accounted for over 509 of pathogens and streptococcal infection was increased. Fungal infection was decreased. 6) In view of the relationship between prophylactic use of oral antibiotics and infecting organism, the ratio of gram-negative to gram-positive organism was 51.3% : 31.6% in group receiving non-absorbable antibiotics and 32.5% : 49.5% in group receiving absorbable antibiotics, therefore the frequency of infection by gram-positive organisms was higher in group receiving absorbable oral antibiotics. Conclusion: Infection has been a major cause of morbidity and mortality in acute leukemia patients, and it is closely related to the severity and duration of leukopenia. Lung was the most common site of infection, gram-negative organism was a predominant pathogen, and gram-positive organism was relatively more common in patients receiving prophylactic absorbable oral antibiotics. Since the spectrum of infection has been changed by many factors, it is necessary to understand this changing pattern and to manage the infection promptly and appropriately.

쯔쯔가무시병 환자에서의 장내 단백 상실

민준기(Jun Ki Min),정우철(Woo Chul Jung),백기현(Gi Hyun Baek),김양리(Yang Ree Kim),오수혁(Soo Hyuk Oh),강문원(Moon Won kang),정인식(In Sik Chung),양우진(Woo Jin Yang),김성훈(Sung Hun Kim) 대한내과학회 1996 대한내과학회지 Vol.51 No.4

N/A Objectives: Tsutsugamushi disease is an acute, febrile illness of humans that is caused by Rickettsia tsutsugamushi. Hypoalbuminemia was reported in some cases of tsutsugamushi disease, but its frequcncy and etiology were not clarified. Therefore we prospectively evaluated fourteen cases of Tsutsugamushi disease patients to idendify intestinal protein loss as a cause of hypoalbuminemia and to assess the value of 99mTc-HSA abdominal scintigraphy for detecting intestinal protein loss. Methods: From November 1994 to December 1994, in fourteen patients with tsutsugamushi disease, serum albumin level and fecal a-1-antitrysin excretion were measured at admission. Anterior abdominal images were obtained at 2, 4, and 24hours after intravenous injection of 30 mCi of Tc-Human serum albumin. Results: 1) The age distribution was mainly in the forties, and fifties. Geographically, 10 cases in the northern part of Kyung-Ki Do and 4 cases in Seoul were occurred. 2) Laboratory findings showed hypoalbuminemia in 5 cases(35.7%), elevated AST and ALT in 11 cases (78.6%), prolonged prothrombin time in 1 cases (7.1%), and proteinuria(30mg/dl) in 9 cases(64.3%). 3) Fecal a-1-antitrypsin concentration was measured in 10 cases of 14 patients with tsutsugamushi disease, of which 8 cases revealed abnormally elevated concentration of fecal a-l-antitrypsin(2.6mg/g dry weight). 4) 99mTc-HSA scintigraphy was positive in 11 of 1478.696) patients with tsutsugamushi disease. 5) In patients with positive 99mTc-HSA scintigraphy, protein loss sites were small bowel(6/11, 54.5%), descending colon(3/14, 27.3%), ascending colon(2/11, 18.1%). Conclusion: Intestinal protein loss was idendified in some patients with tsutsugamushi disease by the measurement of fecal a-1-antitrpysin concentration. 99mTc-HSA scintigraphy is easy and readily available study for detecting intestinal protein loss sites. The comparison of the severity of intestinal protein loss before and after treatment is recommended in patients with tsutsugarnushi disease who have abnormal intestinal protein loss.

소세포 폐암환자에서의 치료에 따른 뇌하수체 - 부신피질계의 변화

박석준(Suk Joon Park),이승헌(Seung Hun Lee),김양리(Yang Ree Kim),김영균(Young Kyoon Kim),송정섭(Jeong Sup Song),이광우(Kwang Woo Lee),박성학(Sung Hak Park) 대한내과학회 1992 대한내과학회지 Vol.43 No.3

N/A Background. Small cell carcinoma of the lung can produce many ectopic hormones, and most frequently ectopic ACTH. The change of the pituitary-adrenal axis is shown more frequently than the ectopic ACTH production, and its squential check reveals some prognostic significance. Methods. We evaluated the 13 patients with small cell carcinoma of the lung, who treated with combined chemotherapy and radiotherapy. The basal ACTH and cortisol, mid-night cortisol, and cortisol after ACTH stimulation were measured at each admission by RIA during 6-kur of chemotherapy. Results. 1) There were 5patients who lost the diurnal variation of serum cortisol. They were all responded to the scheduled treatment, partially or completely. At the same time they recovered from the loss of diurnal variation simultaneously with the therapeutic responses. 2) Non-responders to the ACTH stimulation were 6patients. 2patients among them showed abnormal response initially, but returned to normal response to the ACTH stimulation simultaneously with the response during treatment. Other 4patients showed normal response to the ACTH stimulation initially, but beacame to no response during treatment and finally turned out to normal Cortisol response. Conclusions. Thre are more changes in the pituitaryadrenal axis despite of normal ACTH and cortisol level, and these changes become normalized in almost all of the therapeutic responders.

동종 골수이식 후 만성 이식편대숙주반응 환자에서 발생한 폐렴구균에 의한 수막뇌염 1예

신완식,김병욱,유진홍,김동집,김춘추,박종원,이종욱,김동욱,강문원,김양리 대한감염학회 1993 감염 Vol.25 No.3

Graft-versus-host disease (GVHD) is a frequent complication after bone marrow transplantation. Infectious complications are common in GVHD patients due to defect in cell-mediated immunity. A rare case of S. pneumoniae meningoencephalitis occured in a patient with extensive form of chronic GVHD after allogeneic bone marrow transplantation. He was immediately treated with full dosage of ceftriaxone and ampicillin. He suffered from various complications such as sepsis, acute renal failure, atelectasis, and seizure. Despite of aggressive treatment, he died probably due to renal shutdown and massive subacute cerebral infarction of left cerebral hemisphere. This report showed two unusual and rare features. First, the infection site was CNS rather than respiratory system. Second, the causative organism was S. pneumoniae, which is rare cause of CNS infection in immunocompromised patients.

7개 대학 병원에서 조사한 지역사회 폐렴의 원인균

정문현,김성민,강문원,최희정,정희진,이경원,한성우,송재훈,신형식,김의종,최강원,김민자,박승철,배현주,정윤섭,김준명,백경란,신완식,이규만,김양리 대한감염학회 1997 감염 Vol.29 No.5

목 적 : 폐렴은 많이 발생하면서 사망률이 크게 줄지 않는 질환이며, 이를 적절히 치료하기 위해서는 원인균의 상대적 빈도, 기저 질환에 따른 변화, 항균제 내성률, 사망에 관련된 인자들을 알아야 한다. 원인균의 빈도는 지역마다 차이가 있고 국내에서는 항균제 내성률이 높아 지역사회에서 발생한 폐렴을 치료하기 위한 경험적 항균제 선택에 도움이 되기 위해 서울 소재 6개 대학 병원과 천안의 1개 대학 병원이 참여하여 위의 사항들에 대해 조사를 하였다. 방 법 : 1995년에 내과에 입원했던 16세 이상 환자를 대상으로 했다. 퇴원 진단명이 폐렴 또는 폐결핵인 병록지을 찾았고, 이중에서 병원 감염을 제외하였다. 특이도를 높이기 위해, 이들 중에서 호흡기 증상이 있고 발열이나 저체온이 있으면서 흉부 X-선에서 이상 음영이 있는 환자만을 대상으로 했다. 폐결핵은 위의 기준에 입원 초기에 항균제 치료를 하고 입원 7일 이후에야 항결핵제가 투여된 경우만을 폐렴의 원인균으로 하였다. 혈액 배양에서 양성, 객담에서 항상균이나 M. tuberculosis가 증명된 경우, 혈청학적으로 항체가가 4배 이상 증가된 경우, 조직에서 원인균이 진단된 경우는 확정(definitive) 원인균으로 하였고, 객담에서 배양된 균이 그람 도말과 일치할때, 항결액제에 대한 반응으로 진단한 폐결핵, 단일 항체가 양성이고 이에 대해 항균제를 사용했을 때는 가능(probable) 원인균으로 정의하였다. 다세균 감염균은 각각 다 른 원인균으로 처리하였다. 임상 조사와 함께 임상병리과에서 S. pneumoniae, H. influenzae, M. catarrhalis, mycoplasma, 항상균에 대해 검사 의뢰 건수, 배양 양성수, 항균제 감수성 결과를 조사하였다. 결 과 : 폐렴의 증례 정의에 부합하지 않은 135명과 폐결핵의 정의에 해당하지 않는 230명을 제외하고 남은 246명의 평균 나이는 58.2세이고 남성이 142명(58.2%) 이었고, 71%의 환자에서 기저 질환이 있었다. 진단 방법의 시행 횟수는 혈액 배양 77.6%, 혈청 검사 18.3%, 기관지경 검사는 4.1%였고, 세균의 항원 검사를 한 예는 없었다. 원인균이 밝혀진 예는 77명(31.3%)이었다. 다세균 감염이 4명에서 있었고, 원인균의 상대적 빈도는 결핵 20명(확정 17, 가능 3: 6개 병원 자료), 폐렴구균 18(확정8 가능 10)명과 폐렴구균이 아닌 Streptococcus 3명 (모두 확정), H. influenzae 11명(모두 가능), 그람음성간균 11명(확정 7, 가능 4) (K. pneumoniae 8건), Mycoplasma 5명(확정 1, 가능 4), S. aureus 4명(확정 2, 가능 2), mucormycosis 1명(확정)이었다. 평균 입원 기간은 19일이고, 중환자실 입원률과 인공 호흡기 사용율은 각각 18%와 9.3%였다. 사망률은 13.8%였고 사망까지 평균 기간은 14.6일 이었다. 다변량 분석에서 사망을 예측할 수 있는 인자는 저체온과 빈호흡이었다. 임상병리과에서 배양되었던 모든 폐렴구균의 Penicillin 내성률은 서울 3개 병원에서 82-88%, 천안에서 72%였다. 폐렴 환자의 혈액에서 배양된 7주는 모두 Penicillin에 감수성이 있었다. K. pneumoniae 8주 모두 cefotaxime과 gentamicin에 감수성을 보였다. 결 론 : 후향적 조사이고 병원마다 원인균 진단에 차이가 있지만, 원인이 밝혀진 경우에는 결핵과 폐렴균이 흔하였고, 무균 부위에서 배양된 폐렴구균의 항균제 내성률은 낮았다. 원인이 밝혀지지 않은 경우가 많고, 혈청검사로 진단되는 원인균이 드물며, 분리균주가 적어 항균제 내성 정도를 추정하기 어려워, 이를 밝히기 위한 전향적 조사가 필요하다. Background : Community-acquired pneumonia (CAP) is one of the leading causes of mortality and morbidity, but its management is still challenging. The limitation of diagnostic methods to identify etiologic agents rapidly make it necessary to use empiric antibiotics in almost all patients, and furthermore the discovery of new respiratory pathogens and the emergence of antibiotic-resistant organisms pose difficulties to the selection of an empiric regimen. To clarify the factors necessary for the optimal choice of empirical antibiotics, such as the frequency of etiologic agents, the attributable rates to death and antimicrobial resistance rates in the community, six university hospitals in Seoul and one university hospital in Cheonan were participating in this study. Methods : medical records of adults (>15 years of age) hospitalized for CAP or pulmonary tuberculosis between April 1995 and March 1996, were reviewed. Patients who satisfied all of the following criteria were included in the study: (1) fever or hypothermia; (2) respiratory symptoms; and (3) pulmonary infiltrates on chest roentgenogram. To exclude cases of pulmonary tuberculosis whose roentgenographic features were so typical that it could be easily differentiated from conventional pneumonia, two additional criteria were required for inclusion: antibiotic treatment during the first week of hospital admission and initiation of anti-tuberculosis medications thereafter. Organisms isolated from sterile body sites, acid-fast bacilli or Mycobacterium tuberculosis isolated from sputum, pathogens diagnosed by a 4-fold rising titer of antibodies to “atypical”pathogens, or pathogens revealed by histopathology were defined as definitive cause of pneumonia; isolates from sputum withcompatible Gram stain, pathogens diagnosed by a single diagnostic titer plus use of a specific antimicrobial agent, or tuberculosis diagnosed by clinucal response to anti- tuberculosis medications were considered probable cause of pneumonia. The records of the clinical microbiology were reviewed for isolates of S. pneumoniae, H. influenzae, M. catarrhalis, Mycobacterium or acid-fast bacilli, and Mycoplasma. Then the frequency of these agents, antimicrobial resistance rates of resiratory pathogens from all body sites, and their clinical significance were evaluated. Results: After excluding 365 patients (230 with pulmonary tuberculosis and 135 with CAP) who were screened for inclusion but did not meet the inclusion criteria,246 persons were enrolled in this study. Their mean age was 58.2 years old with slight male predominance (58.2%), and 171(71%) patients had underlying illnesses. Blood cultures were performed on 191 (77.6%) patients and serologic tests on 44(18.3%) patients. The etiologic agents were identified in 31.3%, and the list of individual agents, in decreasing order, was pulmonary tuberculosis (17 definite and 3 probable: data of six hospitals), S. pneumoniae (8 definite and 10 probable), non-pneumococci (3 definite), aerobic gram-negative bacilli (7 definite and 4 probable), Haemophilus spp. (11 probable), mycoplasma (1 definite and 4 probable), polymicrobial infections (2 definite and 2 probable: E. coli and S. agalactiae, M. tuberculosis and S. aureus, S. pneumoniae and H. influenzae and A. baumannii and K. pneumonias), S. aureus (2 definite and 2 probable) , and mucormycosis (1 definite). Among gram-negative bacilli, K. pneumoniae was the most common agent (8isolates). therates of admission to the intensive care unitand of using assisted ventilation were 18% and 9.3%, respectively. The mortality was 13.8% and logistic regression analysis showed that hypothermia and tachypnea were associated with death. Hospital stay averaged 19 days. Susceptible rates of S. pneumoniae isolated from all body sites to penicillin ranged from 8% to 28% but seven isolated from blood of patients with pneumonia were susceptible to penicillin. Also all 8 isolated of k> pneumoniae from patients with pneumonia were susceptible to cefotaxime and gentamicin. Conclusion: In Korea, in addition to S. pneumoniae, M. tuberculosis is an important agent causing community-acquired pneumonia. The low incidence of etiologic diagnosis is probably related to infrequent requesting of test "atypical" pathogens and does not represent the true incidence of infections by "atypical" pathogens, which well be answered by a prospective study. The antimicrobial resistance rates of major respiratory pathogens from sterile body sites are low, however, because of a small number of the isolates this result needs confirmation by a nationwide surveillance of antimicrobial resistance.