Won Yeon Lee

A Case of Autoimmune Progesterone Dermatitis Misdiagnosed as Allergic Contact Dermatitis

Autoimmune progesterone dermatitis is a rare autoimmune response to endogenous progesterone that usually occurs in fertile females. Cutaneous or mucosal lesions develop cyclically during the luteal phase of the menstrual cycle when progesterone levels are elevated. Symptoms usually start 3-10 days before menstruation and resolve 1-2 days after menstruation ceases. We report the case of a 48-year-old woman with intermittent eczematous skin lesions of the legs, forearms, and buttocks. She was diagnosed with allergic contact dermatitis, and topical steroids were prescribed. Her skin eruptions waxed and waned for 6 years and were associated with her menstrual cycle. We performed an intradermal test using progesterone, which was positive, and prescribed gonadotropin-releasing hormone analogues monthly for 3 months. The patients skin lesions improved, confirming the diagnosis. Autoimmune progesterone dermatitis should be included in the differential diagnosis of recurrent eczema that is refractory to treatment in women of child-bearing age.

Acute respiratory distress syndrome caused by miliary tuberculosis: a multicentre survey in South Korea.

BACKGROUND Miliary tuberculosis (TB) is an unusual cause of acute respiratory distress syndrome (ARDS). OBJECTIVE To evaluate the clinical characteristics and outcomes of patients with ARDS caused by miliary TB admitted to the intensive care unit (ICU). DESIGN A total of 67 patients were enrolled during the period 1999-2008. RESULTS The median age of the patients was 56 years (range 17-81), 19 (28.4%) were aged >71 years, and 38 (56.7%) were male. All-cause mortality in the ICU and hospital were respectively 58.2% and 61.2%. Of the total number of enrolled patients, 49 (73.1%) were prescribed anti-tuberculosis medication within 3 days of hospital admission. On the day of ARDS diagnosis (10.0 ± 3.7 vs. 7.4 ± 3.5, P = 0.005), non-survivors had a significantly higher Sequential Organ Failure Assessment (SOFA) score than survivors. Multivariate analysis showed that SOFA score on the day of ARDS diagnosis was a significant predictor of survival (OR 0.809, 95%CI 0.691-0.946, P = 0.008). It was difficult to determine the efficacy of systemic corticosteroids on patient survival. CONCLUSION ARDS caused by miliary TB was associated with a high in-hospital mortality rate, with SOFA score on the day of ARDS diagnosis being a valuable prognostic indicator.

Determinants of Plasma Membrane Wounding by Deforming Stress

Once excess liquid gains access to air spaces of an injured lung, the act of breathing creates and destroys foam and thereby contributes to the wounding of epithelial cells by interfacial stress. Since cells are not elastic continua, but rather complex network structures composed of solid as well as liquid elements, we hypothesize that plasma membrane (PM) wounding is preceded by a phase separation, which results in blebbing. We postulate that interventions such as a hypertonic treatment increase adhesive PM-cytoskeletal (CSK) interactions, thereby preventing blebbing as well as PM wounds. We formed PM tethers in alveolar epithelial cells and fibroblasts and measured their retractive force as readout of PM-CSK adhesive interactions using optical tweezers. A 50-mOsm increase in media osmolarity consistently increased the tether retractive force in epithelial cells but lowered it in fibroblasts. The osmo-response was abolished by pretreatment with latrunculin, cytochalasin D, and calcium chelation. Epithelial cells and fibroblasts were exposed to interfacial stress in a microchannel, and the fraction of wounded cells were measured. Interventions that increased PM-CSK adhesive interactions prevented blebbing and were cytoprotective regardless of cell type. Finally, we exposed ex vivo perfused rat lungs to injurious mechanical ventilation and showed that hypertonic conditioning reduced the number of wounded subpleural alveolus resident cells to baseline levels. Our observations support the hypothesis that PM-CSK adhesive interactions are important determinants of the cellular response to deforming stress and pave the way for preclinical efficacy trials of hypertonic treatment in experimental models of acute lung injury.

Comparison of the Effectiveness of Embolic Agents for Bronchial Artery Embolization: Gelfoam versus Polyvinyl Alcohol

Objective The purpose of this study was to compare the results of different agents for bronchial artery embolization of hemoptysis. Materials and Methods From March 1992 to December 2006, a bronchial artery embolization was performed on 430 patients with hemoptysis. The patients were divided into three groups. Group 1 included 74 patients treated with a gelfoam particle (1×1×1 mm), while group 2 comprised of 205 patients treated with polyvinyl alcohol (PVA) at 355-500 µm, and group 3 included 151 patients treated with PVA at 500-710 µm. We categorized the results as technical and clinical successes, and also included the mid-term results. Retrospectively, the technical success was compared immediately after the procedure. The clinical success and mid-term results (percentage of patients who were free of hemoptysis) were compared at 1 and 12 months after the procedure, respectively. Results Neither the technical successes (group 1; 85%, 2; 85%, 3; 90%) nor the clinical successes (group 1; 72%, 2; 74%, 3; 71%) showed a significant difference among the 3 groups (p > 0.05). However, the mid-term results (group 1; 45%, 2; 63%, 3; 62%) and mid-term results excluding the recurrence from collateral vessels in each of the groups (group 1; 1 patient, 2; 4 patients, 3; 2 patients) showed that group 1 was lower than the other two groups (p < 0.05). No significant difference was discovered for the mid-term results between groups 2 and 3. Moreover, the same results not including incidences of recurrence from collateral vessels also showed no statistical significance between the two groups (p > 0.05). Conclusion Polyvinyl alcohol appears to be the more optimal modality compared to gelfoam particle for bronchial artery embolization in order to improve the mid-term results. The material size of PVA needs to be selected to match with the vascular diameter.

Clinical Practice Guideline of Acute Respiratory Distress Syndrome

There is no well-stated practical guideline for mechanically ventilated patients with or without acute respiratory distress syndrome (ARDS). We generate strong (1) and weak (2) grade of recommendations based on high (A), moderate (B) and low (C) grade in the quality of evidence. In patients with ARDS, we recommend low tidal volume ventilation (1A) and prone position if it is not contraindicated (1B) to reduce their mortality. However, we did not support high-frequency oscillatory ventilation (1B) and inhaled nitric oxide (1A) as a standard treatment. We also suggest high positive end-expiratory pressure (2B), extracorporeal membrane oxygenation as a rescue therapy (2C), and neuromuscular blockage for 48 hours after starting mechanical ventilation (2B). The application of recruitment maneuver may reduce mortality (2B), however, the use of systemic steroids cannot reduce mortality (2B). In mechanically ventilated patients, we recommend light sedation (1B) and low tidal volume even without ARDS (1B) and suggest lung protective ventilation strategy during the operation to lower the incidence of lung complications including ARDS (2B). Early tracheostomy in mechanically ventilated patients can be performed only in limited patients (2A). In conclusion, of 12 recommendations, nine were in the management of ARDS, and three for mechanically ventilated patients.

Risk Factors Related with Mortality in Patient with Pulmonary Tuberculosis

Background The prevalence rate of pulmonary tuberculosis (PTB) is steadily decreasing in South Korea. However, PTB is a disease with relatively high mortality and morbidity rates throughout Korea. Although there are many studies and statistics about the risk factors of PTB mortality in many countries, there are only a limited number of domestic papers on this topic. The aim of this study is to determine predictive factors for mortality among in-hospital patients associated with PTB. Methods From December 2006 to January 2011, we reviewed medical records of 2,122 adult patients diagnosed with tuberculosis at a single tertiary hospital in a suburban area. In this study period, 960 patients were diagnosed with PTB by positive Acid fast bacilli smear and/or mycobacterial culture of the respiratory specimen. We compared the groups of patients deceased and patients discharged alive with PTB. The number of dead patients was 82 (47 males, 35 females). Results Mortality was significantly associated with increased values of white blood cells (WBC), blood urine nitrogen (BUN), creatinine, C-reactive protein (CRP), numbers of involved lung field, and length of hospitalization. Also, it was associated with the decreased values of hemoglobin, lymphocyte, sodium, albumin, and cholesterol. Furthermore, admission through the emergency department, initial intensive care unit admission, and drug resistant PTB affected mortality in PTB patients. Independent predictors associated with PTB mortality are BUN, initial intensive care unit care, and admission during treatment of tuberculosis. Conclusion In our study, mortality of pulmonary tuberculosis was related with parameters associated with nutritional status, disease severity at the time of admission, and drug resistance.

Moderate hemoptysis: recurrent hemoptysis and mortality according to bronchial artery embolization

The studies on hemoptysis have focused mainly on hemoptysis causes and massive or life‐threatening hemoptysis. And there is a limited data that non‐massive hemoptysis, especially moderate hemoptysis.

A Case of Occupational Rhinitis Induced by Maize Pollen Exposure in a Farmer: Detection of IgE-Binding Components

Corn is a major staple food, along with rice and wheat, in many parts of the world. There are several reports of hypersensitivity to maize pollen. However, cases of occupational allergic rhinitis induced by inhalation of maize pollen are very rare. We herein report the case of a 67-year-old male with occupational rhinitis caused by occupational exposure to maize pollen in a cornfield. He showed positive responses to maize pollen, as well as grass pollens, in skin prick tests. A high level of serum immunoglobulin E (IgE) specific to maize pollen extracts was detected by an enzyme-linked immunosorbent assay (ELISA). Laboratory tests showed a high serum level of total IgE (724 kU/L) and a high level of IgE specific to maize pollen (8.32 kU/L) using the Immuno-CAP system. Occupational rhinitis was confirmed by a nasal provocation test with maize pollen extracts. IgE ELISA inhibition tests showed antibody cross-reactivity between maize pollen and grass pollen extracts. IgE immunoblotting using maize pollen extracts demonstrated a 27 kDa IgE-binding component. These findings suggest that maize pollen can induce IgE-mediated occupational rhinitis in exposed workers.

Clinical demographics and outcomes in mechanically ventilated patients in Korean intensive care units

Knowledge of clinical demographics and outcomes of mechanically ventilated patients is important but there are few prospectively collected data in Korea. The objective of the present study was to describe the current status of mechanically ventilated patients in Korea as of 2010. We analyzed the data of Korean patients (275 patients in 12 Korean intensive care units [ICU]) participating in a multinational prospective cohort study on mechanical ventilation. The most common indication for mechanical ventilation was pneumonia (23%). Pressure-limited ventilation modes were preferred over volume-cycled ventilation modes. Non-invasive positive pressure ventilation was used in only seven (2%) patients as the initial ventilatory support. Median duration of mechanical ventilation was 7 days and ICU mortality was 36%. The multiple logistic regression model revealed that the Simplified Acute Physiology Score II (SAPS II) score at ICU admission (odds ratio [OR], 1.034; 95% confidence interval [CI], 1.001-1.036; P=0.033), peak pressure (OR, 1.054; 95% CI, 1.016-1.095; P=0.006), and the number of failed organs (OR, 2.132; 95% CI, 1.634-2.781; P<0.001) were independently associated with ICU mortality. This study provides a snapshot of current practice of mechanical ventilation in Korea. Graphical Abstract

Clinical implications of blood eosinophil count in patients with non-asthma-COPD overlap syndrome COPD.

Background Recent studies that assessed the relevance of the blood eosinophil count as a biomarker in patients with COPD may have overestimated it because they included patients with asthma–COPD overlap syndrome (ACOS). We investigated the clinical implications of the blood eosinophil count in patients with non-ACOS COPD. Patients and methods From a Korean COPD Subtype Study (KOCOSS) cohort, we selected patients with non-ACOS COPD after excluding ACOS patients according to Spanish criteria. Clinical characteristics and the incidence of moderate-to-severe exacerbation were compared among the four groups stratified according to the quartiles of blood eosinophil percent and count. Results Of the KOCOSS cohort of 1,132 patients with COPD, 467 non-ACOS COPD patients (41.2%) with data of blood eosinophil count remained after excluding those with ACOS based on the Spanish definition. There was no difference in clinical characteristics among groups classified according to the quartiles of eosinophil percent and count. On multivariate logistic regression, eosinophil quartiles in percent and absolute count were not associated with the incidence of moderate-to-severe acute exacerbations of COPD (AECOPD). The eosinophil count did not affect the risk of AECOPD or forced expiratory volume in 1 second (FEV1) changes according to exposure to inhaled corticosteroid (ICS). However, by increasing the cutoff value for the eosinophil count from 200/μL to 600/μL, the odds ratio for risk of exacerbation increased serially from 0.82 to 2.96 on trend analysis. Conclusion In patients with non-ACOS COPD, the blood eosinophil count and percent were not associated with FEV1 changes, quality of life (QoL), AECOPD frequency, or response to ICS. The clinical implication of the blood eosinophil count should not be overestimated in patients with non-ACOS COPD.