증례 : 신장; 지연 발현형 급성 인산염 신병증에서 완전 회복된 환자 1예

곽충환 ( Choong Hwan Kwak ),박하연 ( Ha Yeon Park ),김예림 ( Yae Rim Kim ),백진혁 ( Jin Hyuk Paek ),황은아 ( Eun Ah Hwang ),박성배 ( Sung Bae Park ),한승엽 ( Seung Yeup Han ) 대한내과학회 2014 대한내과학회지 Vol.86 No.4

대장내시경 검사 시 경구용 인산염은 폴리에틸렌 글리콘에비하여 적은 용량으로 더 효과적인 장세척이 가능하나 전해질 이상 및 칼슘-인 결정의 침착에 의한 급성 인산염 신병증이 보고되고 있다. 급성 인산염 신병증의 경우 많은 수의 환자들이 만성 콩팥병으로 진행하고 일부는 말기 신부전으로 진행한다고 알려져 있다. 저자들은 조직 검사에서 진단된 급성 인산염 신병증에서 완전 회복된 환자를 경험하였기에 문헌고찰과 함께 보고하는 바이다. The widespread use of colonoscopy for early detection of colorectal pathology has increased the use of osmotic laxatives for colonic cleansing. Among these, oral sodium phosphate preparations can cause renal insufficiency through the development of acute phosphate nephropathy. Acute phosphate nephropathy can be distinguished as early symptomatic and late insidious patterns. Patients whose presentation is insidious are easily overlooked and can progress to chronic kidney disease. We report a case of complete recovery from the late insidious type of acute phosphate nephropathy. (Korean J Med 2014;86:505-509)

관상동맥 중재술을 받은 환자에서 실로스타졸 사용 후 동맥경직도의 변화

조상영 ( Sang Young Cho ),김계환 ( Kye Hwan Kim ),안종화 ( Jong Hwa Ahn ),강영란 ( Young Ran Kang ),고진신 ( Jin Sin Koh ),황석재 ( Seok Jae Hwang ),박용휘 ( Yongwhi Park ),정영훈 ( Young Hoon Jeong ),곽충환 ( Choong Hwan Kwak 대한내과학회 2015 대한내과학회지 Vol.89 No.3

Background/Aims: Increased arterial stiffness is a well-known risk factor for cardiovascular disease. Cilostazol, a phosphodiesterase type 3 inhibitor, is a unique antiplatelet agent with vasodilatory and vasoprotective effects. Therefore, we hypothesized that cilostazol may affect arterial stiffness. Methods: We enrolled 161 patients (112 males; mean age, 63 years) who had undergone percutaneous coronary intervention (PCI) for ischemic heart disease. The brachial-ankle pulse wave velocity (baPWV), radial augmentation index (rAI), rAI adjusted for a heart rate of 75 beats/min (rAI75), central systolic blood pressure (cSBP), and central pulse pressure (cPP), were measured at baseline and at the 30-day follow-up. Parameter changes were compared between the cilostazol group (n = 51) and the control group (n = 110). Results: In the cilostazol group, the values for rAI, cSBP, and cPP all improved after 30 days, while the control group displayed no significant interval changes in these parameters. The changes in rAI75 and baPWV did not differ significantly between the two groups. The changes in rAI, cSBP, and cPP were related to brachial systolic blood pressure, brachial diastolic blood pressure, heart rate, and the use of cilostazol and beta-blockers. In a multivariate analysis, the use of cilostazol was identified an independent factor associated with changes in rAI, cSBP, and cPP. Conclusions: The addition of cilostazol to conventional antiplatelet therapy in patients undergoing PCI may be associated with improvements in rAI, cSBP, and cPP, but not in rAI75 or baPWV. Therefore, the effects of cilostazol might be related to an increased heart rate. (Korean J Med 2015;89:295-304)

복막 투석환자에서 출구 감염의 역학-단일 기관 성적

홍수희 ( Soo Hee Hong ),김정은 ( Jeong Eun Kim ),곽충환 ( Choong Hwan Kwak ),이기태 ( Ki Tae Lee ),황은아 ( Eun Ah Hwang ),한승엽 ( Seung Yeup Han ),박성배 ( Sung Bae Park ),김현철 ( Hyun Chul Kim ) 대한내과학회 2005 대한내과학회지 Vol.69 No.4

목적 : 복막투석 환자에서 출구 감염은 복막염과 더불어 복막투석의 실패 및 환자 사망에 주요한 원인 중의 하나이다. 저자들은 계명의대 동산병원 신장내과에서 복막투석을 시행한 환자를 대상으로 하여 출구 감염의 발생 및 역학에 대해 조사하였다. 방법 : 2001년 1월부터 2003년 12월까지 동산병원 신장내과에서 말기 신부전을 진단받고 복막투석을 시행한 후 1개월 이상 추적관찰이 가능하였던 292명의 환자를 대상으로 하여 출구 감염의 발생률, 원인균, 터널 감염 및 복막염과의 연관성, 치료 결과를 후향적으로 조사하였다. 결과 : 평균 14.5±9.6개월의 추적기간동안 전체 292명의 환자 중 81명(27.7%)에서 97회의 출구 감염을 경험하여 출구 감염의 발생률은 0.27회/환자-년(43.8개월당 1회)였으며 14명(17.3%)의 환자가 반복적으로 출구 감염을 경험하였다. 출구 감염의 원인균으로 그람 양성균이 60.9%, 그람 음성균 8.2%, 혼합 감염 4.1%, 진균 감염 1%였으며 균이 배양되지 않거나 균주를 알 수 없는 경우가 25.8%있었다. 원인균으로는 그람 양성균 중에는 S. aureus가 44.3%로 가장 많았고, 그람 음성균 중에는 Pseudomonas가 4.1%를 차지하였다. 급성 출구 감염은 만성 출구 감염에 비해 치료기간이 유의하게 짧았으며(18.5일 vs, 44.6일, p<0.05), 만성 출구 감염에서는 Pseudomonas 균주에 의한 감염이 유의하게 많았고(p<0.05), 터널 감염의 동반이 높은 경향을 보였다. 치료로 도관 교체가 필요한 경우는 급성 감염이 1예, 만성 감염이 4예로 만성감염에서 유의하게 많았으며 전체 81명의 환자 중 1예가 불응성 복막염이 동반되어 도관을 제거하고 혈액투석으로 전환하였다. 결론 : 복막투석 환자에서 출구 감염의 발생을 감소시키기 위해서는 출구 감염의 진단 및 치료, 예방에 관한 임상적 지침의 확립이 필요하며 이를 위해 더 많은 환자를 대상으로 한 장기간에 걸친 대규모의 잘 대조된 연구가 필요할 것으로 생각한다. Background : Catheter-related infection is one of the most important causes of technical failure in peritoneal dialysis patients. We have examined the incidence and etiology of exit-site infection (ESI) at Keimyung University Dongsan medical center. Methods : Between January 2001 and December 2003, 292 new patients received peritoneal dialysis using double cuffed straight Tenckhoff catheter and were reviewed retrospectively. Results : In 292 patients, 81 (27.7%) patients experienced ESI and a total of 97 episodes of ESI has occurred during study period. The overall incidence of peritonitis during peritoneal dialysis was 0.27 episodes/patient-year. According to Twardowski`s classification, equivocal infection in 14.4%, acute infection in 68.1% and chronic infection in 17.5% were noted. Staphylococcus aureus was the most frequently isolated organism, followed by Staphylococcus epidermidis, and Pseudomonas aeruginosa. The duration of treatment was significantly longer in chronic infection group than acute infection group (44.6 days vs. 18.5 days, p<0.05). The rates of Pseudomonas infection (p<0.05) and catheter replacement (p<0.05) were significantly higher in the chronic infection group than in the acute infection group. There was one catheter loss due to refractory peritonitis and three deaths unassociated with ESI during mean follow-up of 20.3 months. Conclusions : Exit-stie infection is still a major causes of peritonitis and catheter failure. Because of suboptimal quality of practice guideline, additional studies on the definition, prevention and treatment of ESI are required.(Korean J Med 69:395-401, 2005)

급성심근경색에서 Doppler 심초음파도로 진단된 승모판폐쇄부전

정진홍(Jin Hong Chung),황진용(Jin Yong Whang),곽충환(Choong Hwan Kwak),채성철(Schung Chull Chae),전재은(Jae Eun Jun),박의현(Wee Hyun Park) 대한내과학회 1989 대한내과학회지 Vol.36 No.4

N/A In 40 patients with acute myocardial infarction (MI), mitral regurgitation (MR) was determined from the apical 4-chamber and parasternal long-axis views with pulsed Doppler and compared with physical and echocardiographic findings. MR was detected in 19 of the 40 patients (48%) and had a similar frequency in patients with anterior (12 of 24 or 46%) and inferior MI (7 of 14 or 50%). A systolic murmur was heard in 8 of 19 patients with MR detected by Doppler and the murmur was directly related to the degree of Doppler MR, Left atrial and left ventricular (LV) dimensions, mitral annulus circumference and LV ejection fraction were similar in patients with and without Doppler MR. However, the prevalence of Dopopler MR in patients with an LV ejection<30% and/or LV diastolic dimension>5.7cm was 71% (12 of 17) but in those without both it was only 30% (7 % of 23).

난치성 원발성 막성신염 및 초점분절성사구체경화증 환자에서 mycophenolate mofetil의 치료효과

김현철 ( Hyun Chul Kim ),장미현 ( Mi Hyun Jang ),황은아 ( Eun Ah Hwang ),여상목 ( Sang Mok Yeou ),곽충환 ( Choong Hwan Kwak ),한승엽 ( Seung Yeup Han ),박성배 ( Sung Bae Park ),최미선 ( Mi Sun Choe ) 대한신장학회 2010 Kidney Research and Clinical Practice Vol.29 No.6

Purpose: This study was planned to determine the efficacy and safety of mycophenolate mofetil (MMF) as a rescue treatment in patients with membranous nephropathy (MN) and focal segmental glomerulosclerosis (FSGS) who were not responsive to standard therapy with steroid and immunosuppressive regimen. Methods: We planned a prospective, non-randomized study from Oct. 2002 to Aug. 2009, including biopsy-proven MN or FSGS patients in Keimyung university Dongsan hospital. MMF was initiated at 0.5-0.75 g twice daily, and advanced as appropriate or as tolerated to 0.75-1 g twice daily. Results: 14 cases with MN and 5 cases with FSGS was enrolled. The mean age of patients was 51.7±12.3 years, and mean treatment duration was 14.4±6.5 months. Five patients (26.4%) went into complete remission and the seven (36.8%) into partial remission. The mean value of 24hr total urine protein over the follow-up 6 months` period declined significantly from 7.6±6.2 g in pre-treatment, to 4.1±3.2 g in 3 months, and 3.1±2.1 g in 6 months (p=0.011). The mean 24hr total urine protein decreased from 7.5±6.3 g in pre-MMF to 1.9±1.8 g in post-MMF (p=0.001). The mean serum albumin rose from 3.2±0.8 g/dL in pre-MMF to 3.9±0.5 g/dL in post-MMF (p=0.001). There were no significant changes in mean value for WBC, hemoglobin, serum creatinine, and total cholesterol. Side effects of MMF were infrequent and generally mild. Conclusion: MMF appears effective in 63% of patients with MN and FSGS who are resistant to other forms of treatment. Studies with more cases and multicenter controlled trials are required to establish the role and standards of MMF in these disorders.

심부전 환자에서 Tolvaptan 유발 삼투압성 탈수초 증후군 1예

김계환 ( Kyehwan Kim ),강민규 ( Min Gyu Kang ),박정랑 ( Jeong Rang Park ),황진용 ( Jin-yong Hwang ),곽충환 ( Choong Hwan Kwak ) 대한내과학회 2017 대한내과학회지 Vol.92 No.1

저나트륨혈증은 심부전 환자에서 흔하게 관찰되며 이환율 및 사망률의 증가와 관련되어 있다. Tolvaptan은 V2-수용체 항길항제로서 심부전 환자에서 저나트륨혈증의 새로운 치료 약제로 이용되고 있다. 그러나 tolvaptan에 의한 삼투성 탈수초 증후군의 보고는 거의 없었다. 78세 여자가 심부전, 심방세동 및 저나트륨혈증으로 내원하여 tolvaptan을 투여받았다. 약제 처방 후 3일째 갑작스런 소변량 증가 및 혈청 나트륨 증가가 발생하였으며 의식저하가 동반되었다. 고령, 저체중 등의 위험 인자를 가진 심부전 환자에서 tolvaptan의 비정상적인 지연 반응이 나타나 탈수초 증후군이 발생한 증례를 보고하는 바이다. Hyponatremia is commonly encountered in patients with heart failure and has a poor prognosis. Tolvaptan, a novel selective vasopressin V2 receptor blocker, has received attention as an effective drug for treating the syndrome of inappropriate antidiuretic hormone secretion and hypervolemic hyponatremia. However, the safety of tolvaptan in the treatment of hyponatremia is not clear. We experienced a 78-year-old woman with a history of heart failure, atrial fibrillation, and hyponatremia who developed osmotic demyelination syndrome as an unexpected response to treatment with tolvaptan. (Korean J Med 2017;92:62-65)

증례 : 순환기 ; 설인신경통과 동반된 실신 환자에서 영구형 인공 심박동기 치료

조상영 ( Sang Young Cho ),김나영 ( Na Young Kim ),박정랑 ( Jeong Rang Park ),황석재 ( Seok Jae Hwang ),박용휘 ( Yongwhi Park ),황진용 ( Jin Yong Hwang ),곽충환 ( Choong Hwan Kwak ) 대한내과학회 2012 대한내과학회지 Vol.82 No.2

설인신경통은 삼킴에 의해 유발되는 극심한 작열통이 설인신경의 지배 영역인 인두, 편도, 후두 부위에 발작적으로 발생하는 드문 질환이다. 설인신경통으로 유발되는 서맥 또는 심장무수축으로 실신이 발생할 수 있고 치명적인 합병증을 초래할 수 있다. 저자들은 설인신경통에 의해 유발되는 심장무수축에 의한 실신으로 영구형 인공 심박동기 치료를 시행한 증례 1예를 경험하였기에 문헌고찰과 함께 보고하는 바이다. Glossopharyngeal neuralgia is a rare disease that is characterized by sharp pain in the posterior pharynx, tonsils, and larynx, triggered by swallowing. Glossopharyngeal neuralgia can trigger bradycardia or asystole, which can induce life-threatening cardiac syncope. A 55-year-old male was admitted with severe paroxysmal pain in his left jaw and ear, followed by asystole and syncope. We report a patient with cardiac syncope associated with glossopharyngeal neuralgia treated with a permanent pacemaker. (Korean J Med 2012;82:217-220)

증례 : 순환기 ; 인공 심박동기 시술로 치료한 Atrial standstill 1예

조정현 ( Jung Hyun Cho ),안연정 ( Yeon Jeong Ahn ),윤성은 ( Seong Eun Yun ),정영훈 ( Young Hoon Jeong ),최봉룡 ( Bong Ryong Choi ),황진용 ( Jin Yong Hwang ),곽충환 ( Choong Hwan Kwak ) 대한내과학회 2010 대한내과학회지 Vol.78 No.1

본 증례는 가족력 및 다른 특이 질환이 없는 환자에서 발생한 지속성 atrial standstill을 영구적 인공 심박동기를 시술하여 치료하였기에 이제까지 국내에서는 증례보고가 없는 바 문헌고찰과 더불어 보고하는 바이다. Persistent atrial standstill is an extremely rare arrhythmia that was first described by Chavez et al. Electrocardiographically, atrial standstill is characterized by bradycardia, the absence of a P wave, and a junctional narrow complex escape rhythm. Atrial standstill is usually classified into two types. The transient type is observed in drug intoxication, such as with digitalis or quinidine, and hyperkalemia. The persistent type is uncommon, often accompanied by syncopal attacks or brain embolism. We report a case of persistent atrial standstill in an 83-year-old man who was treated with implantation of a permanent pacemaker. (Korean J Med 78:109-112, 2010)

심낭 삼출액 환자에서 Adenosine Deaminase를 근거로 한 항결핵 치료 결정의 적합성

김나영 ( Na Young Kim ),민지현 ( Ji Hyun Min ),안종화 ( Jong Hwa Ahn ),조상영 ( Sang Young Cho ),이은주 ( Eun Ju Lee ),황석재 ( Seok Jae Hwang ),박용휘 ( Yong Whi Park ),곽충환 ( Choong Hwan Kwak ),황진용 ( Jin Yong Hwang ),박정랑 대한내과학회 2012 대한내과학회지 Vol.82 No.4

Background/Aims: The prognostic impact of empirical anti-tuberculous management according to adenosine deaminase (ADA) levels in patients exhibiting pericardial effusion (PE) has not been established. We evaluated the appropriateness of ADA-guided anti-tuberculous medication for patients with PE. Methods: From 2001 to 2010, 47 patients with PE and who were diagnosed with either tuberculous pericarditis (TbP) or idiopathic pericarditis (IP) were enrolled. The diagnosis of definite TbP was made by the presence of Tb bacilli or caseous granuloma in pericardial tissue or effusion. The diagnosis of probable TbP was made by the presence of one or more of the following: (1) elevated ADA (≥ 40 IU/L) in pericardial fluid, (2) positive Tb interferon test, or (3) extracardiac presence of Tb. All clinical information was collected by medical record review and telephone contact. Results: Among the 47 patients with PE, 12 were diagnosed with definite TbP; 17, with probable TbP; and 18, with IP. The mean ADA level was significantly higher in patients with definite TbP than in patients with IP (74.97 ± 36.79 vs. 20.14 ± 7.39 IU/L; p < 0.001). The optimal ADA cutoff value for diagnosis of definite TbP was 64 IU/L. The median follow-up time was 12.1 months (range, 0.17-100 months). In patients with low levels of ADA (< 40 IU/L), the incidence of death or recurrence did not different between patients who were prescribed anti-tuberculous medication and those who were not. Conclusions: The ADA level in pericardial fluid was useful for making a rapid diagnosis of tuberculous pericarditis. Even in tuberculosis-endemic areas, patients with ADA < 40 IU/L may have a good prognosis without empirical anti-tuberculous treatment. (Korean J Med 2012;82:441-448)

증례 : 순환기 ; 영구형 인공심박동기 삽입술 후 발생한 스트레스성 심장 근육병증 1예

강민규 ( Min Gyu Kang ),김나영 ( Na Young Kim ),박정랑 ( Jeong Rang Park ),황석재 ( Seok Jae Hwang ),박용휘 ( Yong Whi Park ),곽충환 ( Choong Hwan Kwak ),황진용 ( Jin Yong Hwang ) 대한내과학회 2012 대한내과학회지 Vol.82 No.5

Stress-induced cardiomyopathy is a disease characterized by acute transient left ventricular dysfunction following exposure to stressful situations. We encountered an 80-year-old woman with complete atrioventricular block and normal LV systolic function. After permanent pacemaker implantation, electrocardiogram showed inverted T-waves in precordial leads. Follow-up echocardiographic findings indicated dyskinesia of the apical wall. Final diagnosis was stress-induced cardiomyopathy associated with a physically stressful condition (i.e., pacemaker implantation). (Korean J Med 2012;82:609-613)