Yeontae Chung

Two patients with microscopic polyangiitis and unusual pulmonary manifestation.

Abstract: We encountered two patients with microscopic polyangiitis (MPA) associated with unusual pulmonary manifestations. The first patient was a 45‐year‐old man who had worked in a mine for 3 years when he was young. On admission, chest X‐rays showed long‐standing silicosis and a new patchy infiltration. The second patient was a 52‐year‐old female. On admission, chest X‐rays showed bilateral patchy infiltrations. Since then, variable patterns of patchy infiltration have waxed and waned repeatedly. The renal biopsy revealed that both patients had glomerulonephritis associated with small vessel vasculitis but with few or no immune deposits. There was neither granulomatous inflammation nor eosinophilic infiltration. Myeloperoxidase‐antineutrophil cytoplasmic antibody (ANCA) was positive in both patients. After treatment with glucocorticoids and cyclophosphamide, radiological findings were minimal and stable. These two cases show that patients with MPA have a wide spectrum of radiological findings.

Two Cases of Respiratory Failure After Recovery of Cholinergic Crisis in Organophosphate Poisoning: The Intermediate Syndrome

급성 유기인제 중독에서의 주사망 원인인 호흡부전은 급성 콜린성 위기시에 발생하지만 콜린성 위기에서 회복된 후 콜린양 증상의 동반없이 24-96시간에 근위부 사지근육, 경부굴근 및 운동뇌신경 분포근육의 무력증과 함께 호흡부전이 발생하기도 한다. 이를 IMS이라 하며 조기에 인지하고 적절히 치료하지 못했을 때 호흡근 마비로 사망 할 수 있어 모든 유기인제 중독환자를 최소 5일 이상 병원내에서 무호흡보조 치료에 대한 준비상태를 갖추고 근접관찰 하여야 한다. 저자들은 유기인제 중독에서 콜린성 위기 회복후 호흡부전을 유발한 IMS 2 례를 경험하였기에 문헌고찰과 함께 보고하는 바이다. 【Respiratory failure is the most serious manifestation and usual cause of death in acute organophosphate poisoning, and is common in acute cholinergic crisis. But the respiratory failure may appear suddenly in a patient who is recovering from the cholinergic crisis, even while receiving conventional therapy. These are case report of 37 years old male and 24 years old female with intermediate syndrome in organophosphate poisoning. The two patients ingested organophosphate(fenthion and mixture of DDVP with chlorpyrifos respectively) incidentally and in a sucide attempt respectively. After apparent recovery from the cholinergic crisis with a conventional therapy but before the expected onset of delayed polyneuropathy, the respiratory failure appeared suddenly with a muscular weakness, affecting predominantly the proximal limb muscles, neck flexors, territories of several motor cranial nerves. The two patients needed mechanical ventilatory support and recovery from the intermediate syndrome was complete in both patients, although one subsequently developed hypoxic encephalopathy. The clinical manifestation and electrophysiologic study support the clinical diagnosis of intermediate syndrome. The syndrome carries a risk of death. because of respiratory paralysis, if not recognized early and treated adequatedly. Prompt endotrachial intubation and mechanical ventilatory support is the cornerstone of treatment of the intermediate syndrome. Therefore, all patient should be observed in a hospital for up to 5 days after poisoning.】

A Case of Sarcoidosis with Bone Involvemnt

Sarcoidosis is a chronic multisystemic disorder of unknown cause characterized by presence of noncaseating Epithelioid granuloma in affected organ. It was first reported in 1887 by Hutchinson and is relatively common in western countries. But it is not commonly seen in East Asia including Korea. All parts of the body can be affected, but the lung is the most frequently affected organ. Other common site of involvement include lymph node, eye, skin, etc. It is known that 3~9% of all cases of sarcoidos is associated with bone involvement. Bone involvement usual1y cause no symptom and frequently affect bones in hands an feet. In many cases, it is known to be associated with skin involvement. We recently experienced one case of sarcoidosis which typically showed X-ray finding of sarcoidosis with associated skin lesion(lupus pernio) and report it with review of the literature.

Weaning Following a 30 Minutes Spontaneous Breathing Trial

Background : Weaning is the process of switching a patient from mechanical ventilator to spontaneous breathing. A number of different weaning techniques can be employed. At recent study, conventional spontaneous breathing trial was superior to other techniques, such as intermittent mandatory ventilation(IMV) or pressure support ventilation(PSV). But adequate observation time of the spontaneous breathing trial was not determined. We reported the effectiveness of weaning and extubation following a 60 minutes spontaneous breathing trial with simple oxygen supply through the endotrachial tube. In this study, we tried to shorten the spontaneous breathing time from 60 minutes to 30 minutes. If weaning success was predicted after 30 minutes spontaneous breathing, extubation was done without reconnection with ventilator. Methodes : Subjects consisted of 42 mechanically ventilated patients from August 1994 to July 1995. The weaning trial was done when the patients recovered sufficiently from respiratory failure that originally required ventilatory assistance, the patients became alert and showed stable vital sign, and arterial tension was adequated( > 55 mmHg) with less than 40% of inspired oxygen fraction. We conducted a careful physical examination when the patients was breathing spontaneously through the endobronchial tube for 30 minutes. We terminated the trial if a patients was any of following signs of distress; cyanosis, diaphoresis, tachypnea(above 30 breaths per minute), and extreme tachycardia. Patients who had none of this features during spontaneous breathing for 30 minutes were extubated promptly. Result : 17 weaning trials of 15 patients were done in 42 mechanically ventilated patients. Successful weaning and extubation was possible in 14 trials of total 17 trials. In this 14 patients, 8 patients were extubated after 30 minutes spontaneous breathing, 3 patients were extubated after 60 minutes spontaneous breathing, and 3 patients needed over 3 hours for extubation from weaning. We found similar overall success rate compared with weaning following a 60 minutes spontaneous breathing trial. Conclusion : From the result of present study, we believe that weaning and extubation from mechanical ventilation following a 30 minutes spontaneous breathing with supply through the endotracheal tube is a simple and effective method.