최정민, 김상균, 김주성, 정현채, 송인성 서울대학교 의과대학 내과학교실, 간연구소 대한소화기내시경학회 집담회 증례 발표 2008. 12. 2 최정민, 김상균, 김주성, 정현채, 송인성 서울대학교 의과대학 내과학교실, 간연구소

증례 1st Admission 여자, 49세 C.C: 하루 10회의 수양성 설사와 복통 Onset: 20 days ago Watery, non-mucoid, not bloody 식사와 관계없음 N/V(+/+), anorexia(+), wt loss: 5kg/1mo fever/chill(-/-) 과거력 만성 폐쇄성 폐질환 (+) 당뇨/고혈압/결핵/간염; 모두 부인함.

신체검진 Initial lab V/S : 101/68 mmHg – 85 bpm - 22/min - 37.3⁰C Both lung: crackle(+) Abdomen: whole abdominal T(+)/RT(-) Initial lab CBC: WBC 15,500 – Hb 13.4 – PLT 363K CRP 3.26 Na 142- K 2.3 - Cl 119-CO2 21 LFT: AST/ALT 57/23 ALP 39 GGT 22 T-Bilirubin 0.5 Prot/Alb 4.6/1.8 Cholesterol 85 Stool: no parasite, no growth, occult blood(+)

Abdomen+pelvis CT Pneumatosis coli at rectum and S-colon 2008년 8월 25일 Pneumatosis coli at rectum and S-colon Small bowel wall enhancement Pneumatosis coli at rectum and S-colon with localized intraabdominal free air in meserectum and mesocolon Segmental mild edematous wall thickening of A-colon, cecum and small bowel with mucosal enhancment 결론 diffuse enterocolitis, such as infectious colitis

Colonoscopy 2008년 9월 3일 T-Ileum Rectum Erosion and hyperemic mucosa was scattered in the T-ileum, T-colon, rectum T-Ileum Rectum

Colonoscopy 2008년 9월 3일 T-colon Erosion and hyperemic mucosa was scattered in the T-ileum, T-colon, rectum T-colon

대장내시경 조직검사 c/w amebiasis Ileum, terinal, endoscopic biopsy: Active ileitis (#1) with 1) mucosal sloughing 2) crypt depletion 3) lymphoplasmacytic infiltration in lamina propria Rectum, endoscopic biopsy: Consistent with amebic proctitis (#2)

Hospital course 2nd Admission IV ceftriaxone + metronidazole TPN Stool C. difficile toxin(+) Metronidazole p.o 설사 및 복통 호전되어 퇴원함 2nd Admission 다시 재발된 복통과 설사 (>5/day)

신체검진 Lab V/S : 98/63 mmHg – 114 bpm - 22/min - 37.3⁰C CBC: WBC 15,500 – Hb 7.4 (MCV 102, MCHC 31) – PLT 363K BUN/Cr: 32/2.1 Na 159- K 2.3- Cl 140-CO2 12 LFT: AST/ALT 57/23 ALP 402 GGT 380 Prot/Alb 4.6/1.8 T-Bilirubin 10.5 24hr urine protein 1890 mg/d Ferritin 544 vit b12 1660 24hr urine protein 1898mg/day na 322 cr

Capsule endoscopy 2008년 9월 29일 Proximal Jejunum Irregular ulcer and diffuse edema r/o lymphoma, Proximal Jejunum

Small bowel enteroscopy 2008년 9월 30일 Mid jejunum small bowel villi 소실 Granular pattern mucosa Mid jejunum hyperemic erosion bx: r/o lymphoma, intestinal lymphangiectasia Proximal Jejunum

소장내시경 조직검사 CMV infection consistent with CMV infection

Lab FANA 1:320, anti ds DNA 4.6 C3, C4 감소, Anti-Sm Ab:positive 병력상 alopecia, rash ANCA(-) HIV Ab(-) Lupus anticoagulant(-) Anticardiolipin antibody(-) Ferritin 544 vit b12 1660 24hr urine protein 1898mg/day na 322 cr

과거 대장내시경 조직검사 CMV infection

Summary Diagnosis Treatment CMV enterocolitis SLE with lupus enteritis IV ganciclovir IV steroid 설사, 복통 호전되어 퇴원함 10/9-10/29 ganciclovir 10/11-11/2 iv methylPD사용후 PO로 바꿈

Hospital course 2008.10.09 2008.10.19 2008.10.29 2008.11.05 Discharge CMV enteritis Lupus enteritis Methyl-PD 50mg(10/11-11/1) PD 40mg PD 30mg 15 Ganciclovir(10/9-10/29) Lab: LFT정상, prot/alb 5.5/2.5 bun./cr 10/0.7 UA alb 1+ Diarrhea >5 /day, NPO <2 /day Diarrhea free, NRD Abdominal pain(~10/21) Pain free

GI manifestation in SLE Lupus enteritis (enteral vasculitis) Good response to high dose steroid Necrosis and perforation necessitate surgery Bowel wall thickening, engorgement of mesenteric vessels, high attenuation of mesenteric fat on CT Protein losing enteropathy Diarrhea Diagnostic method: Tc99m-albumin scintigraphy respond to steroids Hepatomegaly, LFT abnormality, pancreatitis Autoimmune hepatitis