증례 : 류마티스 ; 아나킨라로 호전된 급성 폐렴을 동반한 성인형 스틸병

조성하 ( Soung Ha Cho ),김원중 ( One Zoong Kim ),조상우 ( Sang Woo Cho ),임동민 ( Dong Min Lim ),안수경 ( Su Kyoung An ),김춘관 ( Choon Kwan Kim ) 대한내과학회 2014 대한내과학회지 Vol.87 No.2

Adult onset Still`s disease (AOSD) is a systemic autoinflammatory disorder that presents with recurrent fever, extreme fatigue, and joint pain. Pulmonary involvement is not uncommon and, although rare, severe pneumonitis can progress to respiratory failure. Still`s disease-associated pneumonitis is generally treated with immunosuppressive agents, but improvement in our understanding of systemic inflammatory processes led us to explore alternative agents. Anakinra is an interleukin-1 receptor antagonist used to treat autoinflammatory disorders resistant to immunosuppressive therapy. Several case reports have demonstrated efficacy of anakinra in treating AOSD, but its relevance in cases complicated with severe pneumonitis has not been examined. Our patient`s disease activity was not controlled with systemic steroids and cyclophosphamide. Treatment with anakinra led to a dramatic clinical response. This is the first reported case of AOSD with severe pneumonitis refractory to conventional therapy successfully treated with anakinra. (Korean J Med 2014;87:245-250)

단일한 간종괴로 발현된 간질증

이종철(Jong Chul Lee),백승운(Seung Woon Paik),김재준(Jae Jun Kim),고광철(Kwang Cheol Koh),고영혜(Young Hyeh Ko),이화영(Hwa Young Lee),김춘관(Choon Kwan Kim),이풍렬(Poong Lyul Rhee),오영륜(Young Lyun Oh) 대한소화기학회 1997 대한소화기학회지 Vol.30 No.5

Fascioliasis, infection of fasciola sp., is a zoonotic liver disease in human which usually involves the liver and biliary tract. Its occurrence is common in tropical area, western America and in the Mediterranean region, but relatively uncommon in Korea. Fascioliasis is usually presented as multiple small liver abscess and it is extremly uncommon as a single large liver mass. We experienced a case of facioliasis. In an asytnptomatic 43 year-old woman, appearing as a single, large hepatic mass. Imaging study suggested that the rnass is likely to be a hetnangioma, hepatoma or metastatic lesion. We carried out fine needle aspiration of the liver, and its cytology showed only some Fasciola sp. egg. Patients serology to the parasite wasnt available at that time, so we carried out partial hepatic lobectomy to confirm the diagnosis of fascioliasis. We found a parasite granuloma, mummified adult worm of fasciola sp. (Korean J Gastroenterol 1997; 30: 689-694)

증례 : 류마티스 ; 루푸스와 연관된 혈구포식 림프조직구증에서 Etoposide 병합치료 1예

한승완 ( Sung Wan Han ),강규근 ( Kyu Keun Kang ),박소현 ( So Hyun Park ),송지영 ( Ji Young Song ),유웅선 ( Woong Sun Yu ),최정란 ( Jung Ran Choi ),김춘관 ( Choon Kwan Kim ) 대한내과학회 2013 대한내과학회지 Vol.84 No.4

50세 여자 환자를 SLE 연관 HLH로 진단하고, 면역억제치료에도 호전되지 않아 etoposide를 주사 후 호전된 증례 1예를 보고하는 바이다. Hemophagocytic lymphohistiocytosis (HLH) can develop following strong activation of the immune system and the cardinal symptoms are a prolonged fever, hematological abnormalities, hepatosplenomegaly, and hemophagocytosis. HLH can be classified as primary or secondary HLH, associated with infections, malignancy and autoimmune disease. There is no consensus on the primary treatment regimen in systemic lupus erythematosus (SLE)-associated HLH. We experienced a case of SLE-associated HLH in a previously healthy adult. She was initially treated with intravenous immunoglobulin, cyclosporine, and high-dose steroid, but had a poor clinical response. After intravenous etoposide, the patient stabilized and has been followed for 1 year without reactivation of the HLH or SLE. (Korean J Med 2013;84:613-618).

중증 열대열 말라리아 환자의 부검 1 예

김춘관,김성민,백경란,이정원,서연림,송재훈 대한화학요법학회 1997 대한화학요법학회지 Vol.15 No.1

저자들은 아프리카 지역을 여행한 후 중증 열대열 말라리아에 이환되어 뇌형 말라리아, 급성 신부전, 급성 호흡부진 증후군, 범발성 혈관내 응고등 중증 합병증으로 사망하여 부검한 1예를 경험하였기에 이를 문헌 고찰과 함께 보고하는 바이다. As tourism is dramatically increasing, imported infectious diseases pose a serious threat to international travelers. Malaria would be the most important one. Particularly, falciparum malaria can be complicated by cerebral malaria, acute renal failure, acute respiratory distress syndrome, dissenminated intravascular coagulation, severe anemia, and death. We report a fatal case of falciparum malaria after travel to Afrca. A 49-year-old man was admintted to the hospital because of fever, jaundice, and altered mentality. The patient did not take any chemoprophylaxis before and during his stay in Africa. Blood smear was characteristic for falciparum malaria with heavy parasitemia(>50%). Although quinine dihydrochloride was promptly instituted, the patient was complicated by comatous mentality, acute renal failure, adult respiratory distress syndrome, disseminated intravascular coagulation, and refractory hypotension. Despite of intensive care with mechanical ventilator, continuous hemofiltration, the patient expired on the 4th hospital day. Autopsy revealed parasitised red blood cells and malarial pigments in capillaries and small vessels in most organs throughout the entire body.

급성 세균성 부비강염에 대한 Cefpodoxime proxetil의 치료효과

김춘관,이혁,김성민,백경란,동헌종,나동규,송재훈 대한화학요법학회 1998 대한화학요법학회지 Vol.16 No.4

목적 Cefpodoxime proxetil은 새로이 개발된 제3세대 경구용 세팔로스포린 항균제이다. 그람양성과 그람음성균에 넓은 항균력을 가지고 있으며 특히 페니실린 내성 폐렴구균에 중등도로 효과가 있다. 이에 저자들은 시험관 내에서 폐렴구균에 대한 cefpodoxime의 감수성 여부를 조사하고, 급성 세균성 부비강염에 대한 cefopdoxime proxetil의 임상적 효과 및 안전성을 검토하기 위해 이 연구를 시행하였다. 방법 임상 검체에서 분리되어 보관하고 있는 폐렴구균 100 균주를 대상으로 cefodoxime 디스크를 이용하여 항균제 감수성 여부를 조사하였다. 또한 1996년 9월부터 1996년 12월 까지 삼성의료원에 내원한 33명의 급성 세균성 부비강염 환자를 대상으로 cefpodoxime proxetil 200mg을 14 일간 부여하였다. 환자들은 치료를 전후하여 임상 증상 및 증후를 비교하고, 세균검사, 임상 검사, 방사선학적 검사를 시행하였다. 결과 페니실린 감수성 폐렴구균 24균주와 페니실린 중등도 내성 26 균주 모두 cefpodoxime에 감수성이 있었다. 페니실린 내성 폐렴구균 50 균주중 78% 에서 감수성이 있었고 나머지 22%는 내성을 보였다. 임상적 호전을 보인 환자는 전체의 96%였다. 단순 방사선 촬영과 CT를 기초로 판단한 방사선학적 호전율은 69%였다. 약제 부작용은 전체 33명 중 관찰되었고 소화기계 증상과 두통이 각각 2명에서 관찰되었으며, 두통이 발생한 2명은 그 정도가 심하여 투약을 중지하였다. Background : Cefpodoxime proxetil is a new third-generation cephaiosporin. It has 2 broad antibacterial spectrum and shornrs potent antibacterial activity against respiratory pathogens, including Huemophilus in fluenzae, Streptococcus pneumoniae, and Moraxella catarrhalis. Moreover, it has inoderate activity to penicillin-resistant Streptococcus pneumoniue, the incidence of which is increasing worldwidely. Therefore, cefpodoxirne proxetii can be recommended as an empirical antibiotic for treatment of acute bacterial sinusitis. The aim of this study is to reassure In vitro antimicrobial activity of cefpodoxirne to Streptococcus pneumoniae including penicillin-resistant strains and to evaluate the therapeutic efficacy and the safety of cefpodoxiine proxetii in acute bacterial sinusitis. Method : In vitro antimicrobial activities of cefpodoxime to 100 S. pneumoniae isolates from clinical specimens were investigated by disk diffusion method. Clinically. cefpodoxime proxetil mas admmmstered 200 mg twice a day orally for 14 days in 33 patients with acute bacterial smus~tis. The therapeutic efficacy was evaluated by patient's clinical s tom and signs, and by radiologic frndings of simple X-ray of paranasal sinuses and CT. Results : In vitro, penicillin sensitrve(n= 26) and intermediately resistant(n=26) S. pneumontae were all susceptible to cefpodoxime. Among 50 isolates of penicillin resistant s. pneumoruae, 39 strains(78%) were cefpodoxime sensitive and 11 strains(22%) were intermediately resistant to cefodoxime. Clinical symptoms and signs were improved in 32 patients(96%) of the patients. Radiological improvernent were found in 23 patients(69%). During treatment, headache and abdominal discomfort were developed in 2 patients, respectively. Conclusion : Cefpodoxime proxetil was highly effective and safe in treating acute bacterial sinusitis.

단일한 간종괴로 발현된 간질증 1예

김춘관,이화영,백승운,이풍렬,김재준,고광철,이종철,오영륜,고영혜 大韓消化器病學會 1997 大韓消化器病學會誌 Vol.30 No.5

조직학적 진단된 chronic necrotizing pulmonary aspergillosis 2예

김연숙,정숙인,기현균,김춘관,김신우,한정호,김성민,백경란,송재훈 대한화학요법학회 2000 대한화학요법학회지 Vol.18 No.1

CNPA는 기존의 폐질환 및 폐절제술로 인해 국소방어기전에 저하가 있거나 비특이적 전신면역상태저하를 갖고 있는 환자들에게서 주로 발생하는 만성적인 공동성 폐질환이다. 현재까지 우리나라에서는 CNPA의 보고가 없는 상태이고, 저자들은 최근 조직학적으로 진단된 CNPA 2예를 경험하였기에 보고하는 바이다. 저자들이 경험한 CNPA 환자들은 만성알코올 중독 및 기관지확장증과 같은 기저질환과 폐절제술을 받은 병력이 있었다. Aspergillus가 폐실질을 침윤하고 있는 조직소견과 조직배양에서 Aspergillus가 검출되어 조직학적 진단이 가능하였고, amphotericin B의 정주요법 및 경구 itraconazole 투여와 폐절제술 등으로 성공적으로 치료되었다. 아직 많은 임상의들에게는 낯선 질환인 CNPA의 치료성적은 환자의 동반질환 및 CNPA 자체의 중증도, 진단과 치료 시작의 지연 등에 의해 크게 좌우되므로 만성적으로 진행하는 공동성 폐병변을 갖고 있는 환자에게서 CNPA를 감별하는 것이 중요하다. Chronic necrotizing pulmonary aspergillosis (CNPA) is a chronic cavitary form of pulmonary aspergillosis. Dozens of CNPA cases have been reported in patients with systemic immunologic dysfunction or altered local defense mechanism from preexisting pulmonary disease. Review of literatures revealed that no CNPA cases have been reported in Korea yet. We experienced two cases of CNPA proven by lung biopsy. A 53-year-old alcoholic male in poor nutritional state was admitted with generalized weakness and weight loss. Chest CT revealed a cavitary nodule surrounded with ground-glass attenuation. CT-guided fine needle aspiration and biopsy was done. The biopsy specimen demonstrated dichotomously branching septated hyphae consistent with those of Aspergillus sp. Another case was a 39-year-old man with bronchiectasis who was admitted with persistent hemoptysis. He had a past history of pulmonary tuberculosis. A parahilar lesion with intracavitary soft tissue mass was incidentally detected in high-resolution GT. Left lingular segmentectomy was done due to uncontrolled hemoptysis and CNPA was histologically diagnosed. Both patients were successfully treated with intravenous amphotericin B followed by oral itraconazole. Even though CNPA is unfamiliar to most clinicians, it should be included in differential diagnoses of chronic progressive cavitary pulmonary lesion, especially in patients with immunologic dysfunction.

Ochrobactrum anthropi 패혈증 1예

김춘관,안석진,하경원,현재근,김성민,백경란,이남용,송재훈 대한내과학회 1997 대한내과학회지 Vol.53 No.3S

저자들은 비호지킨씨 림프종으로 항암 치료를 받고 있는 환자에게, 감수성있는 항균제 투여와 중심정맥 카테터를 제거함으로써, 중심정맥 카테터와 관련된 O.anthropi 패혈증을 성공적으로 치료한 1예를 경험하였다. O. anthropi 감염이 세계적으로 드물고, 국내에서는 그 보고가 없었으나, 이 균이 Pseudomonas와 유사해서 동정이 잘못될 수 있으며, 중심정맥 카테터를 가지고 있는 면역 억제된 환자에서 호발됨을 고려해 볼 때, 향후 더 많은 관심을 가져야 할 것이다. Ochrobactrum anthropi is a gram-negative, oxidase producing, non-lactose fermenting bacilli. It was formerly known as CDC Group Vd with confusions in taxonomical classification. Although there have been few reports of O. anthropi infection in English literatures, it may be related to central venous catheter infections, especially in the immunocompromised hosts. We report a case with sepsis due to O. anthropi, who had a central venous catheter and chemotherapy for non--Hodgkin's lymphoma, with review of the literatures. O. anthropi was isolated from blood culture and identified with biochemical tests. We successfully treated the patient with removal of Hickman catheter and antibiotics. To our knowledge, this is the first case of O. anthropi infection in Korea.

성인에서 발견된 요붕증과 동반된 랑게르한스 세포 조직구증 1예

김춘관,김광원,이문규,민용기,이명식,고은미,정재훈,안규정,정만표 대한내분비학회 1996 Endocrinology and metabolism Vol.11 No.3

In Langerhans cell histiocytosis, diabetes insipidus is the most common endocrinologic complication. We experienced a case of Langerhans cell histiocytosis, involving pituitary stalk and lung. The patient was a 43 year old male with complaint of polyuria and polydipsia. The water deprivation test was carried out to confirm the diagnosis of diabetes insipidus. We found multiple small cysts and nodules in HRCT of lung, and diagnosed Langerhans cell histiocytosis by transbronchial lung biopsy, The patient was managed conservatively with DDAVP nasal spray. The polyuria,polydipsia was relieved completely. After that, we follow up and observe closely the patients lung and pituitary lesion(J Kor Soc Endocrinol 11:330-335, 1996)

토끼 수막염 모델을 이용한 다제내성 폐렴구균에 대한 Meropenem의 치료 효과

김신우,진정화,강수정,정숙인,김연숙,기현균,김춘관,이혁,김성민,백경란,송재훈 대한화학요법학회 2001 대한화학요법학회지 Vol.19 No.1

목적 : 다제내성 폐렴구균에 의한 수막염은 기존과 단일 항생제로는 근치가 어려워 ceftriaxone과 vancomycin 혹은 rifampin의 병용요법이 권유되고 있다. 다제내성 폐렴구균에 사용할 수 있는 다른 약제 중 meropenem은 시험관내 폐렴구균에 대한 항균력이 좋고 경련 등의 중추신경계 부작용이 거의 없어 다제내성 폐렴구균에 의한 수막염의 치료에 이용할 수 있을 것으로 기대되나 이에 대한 자료가 매우 부족한 상태이다. 이에 연자 등은 meropenem과 meropenem+vancomycin의 병용요법이 다제내성 폐렴구균 수막염의 치료에 효과가 있는지를 토끼 수막염 동물 모델을 이용하여 검증하고자 하였다. 방법 : 인체에서 수막염을 일으킨 다제내성 폐렴구균 균주(penicillin MIC 2, ceftriaxone MIC 4, meropenem MIC 0.5㎍/㎖)를 토끼 척수강 내에 직접 주입하여 수막염을 유발한 후 ceftriaxone, vancomycin, rifampin, meropenem의 단일 항균요법, ceftriaxone+vancomycin, ceftriaxone+rifampin, meropenem+vancomycin의 병용요법 간에 치료 효과의 차이를 비교 하였다. 각 치료군은 6 마리의 토끼를 대상으로 하였다. 각각의 항생제는 5 시간 간격으로 2번 정주하였으며, ceftriaxone은 1회 투여하였다. 균주 주입 후 각 치료군이 토끼에서 치료 후 0, 5, 10, 24 시간에 척수액을 채취하여 균주의 수를 측정하여 24시간째의 살균 여부를 최종 치료 효과로 판정하였다. 결과 : meropenem 단독 요법은 10시간째에 모든 균주를 살균하였으나 24시간 째에 다시 균의 성장이 관찰되었으며, meropenem+vancomycin의 병용요법은 단독 약제보다 우수한 살균효과를 보였으나 상승작용은 없었다. 결론 : meropenem+vancomycin의 병용요법은 기존의 ceftriaxone+vancomycin보다 24시간째에 더 큰 균의 감소 경향을 보여(P=0.054) 임상에서 사용이 가능할 것으로 기대되며 향후 실제 수막염 환자에서의 임상효과를 증명하는 연구가 필요할 것으로 생각된다. Background : Because antimicrobial monotherapy for pneumococcal meningitis caused by penicillin-resistant strains is not satisfactory, ceftriaxone+vancomycin [C+V] or ceftriaxone+rifampin [C+R] regimens are recommended. Meropenern [M] is one of the monotherapy options for penicillin-resistant pneumococcal meningitis due to good in-vitro activity against pneumococci and rare adverse reactions in CNS. But there have been few reports in the efficacy of meropenern against pneumococcal meningitis. We evaluated therapeutic efficacy of the meropenern and meropenem+vancomycin in a rabbit model of meningitis caused by penicillin-resistant S. pneumoniae (PRSP). Methods : Meningitis was induced by intracistemal inoculation of a pneumococcal strain isolated from a patient with meningitis (MIC; penicillin 2, ceftriaxone 4, meropenem 0.5 g/㎖). Bacterial concentrations in the CSF were measured at 0, 5, 10, and 24 h after therapy was started. Therapeutic efficacy was evaluated by the final bacterial concentration in the CSF at 24 h. Results : C+V cleared the CSF at 10 h, but regrowth of bacteria was noted at 24 h. Meropenem monotherapy resulted in sterilization at 10 h but regrowth at 24 h. M+V was superior to M or V monotherapy but did not show synergism. Therapeutic efficacy of M+V was at least equal or superior to that of C+V (P = 0.054). Conclusion : Meropenem+vancomycin regimen could be one of the useful options in the treatment of PRSP meningitis. Clinical trials to evaluate the M or M +V are warranted in the future.