A 25-year-old woman presented with jaundice, palpitation, and weight loss of 5 kg during a period of 2 weeks. Laboratory tests showed elevated levels of liver enzymes (AST 1,282 IU/L, ALT 1,119 IU/L) and total bilirubin (6.4 mg/dL); negative for hepatitis virus infection; elevated serum levels of triiodothyronine (T3, 3.60 ng/dL), free thyroxine (fT4, 3.82 ng/dL), and lowered serum level of thyroid stimulating hormone (TSH, <0.025 microIU/mL); and positive for thyroid stimulating antibody and anti-mitochondrial antibody (AMA). The liver biopsy findings were consistent with autoimmune hepatitis (AIH). Accordingly, oral steroid therapy was started with 60 mg of prednisolone under the impression of AIH associated with Graves' disease. After a week of steroid therapy, the clinical manifestation showed significant improvement, with normalization of both liver and thyroid functions. Diagnosis of the liver condition of patients who present with hyperthyroidism and liver dysfunction is important, so that appropriate therapy can be promptly initiated.
Adult ; Alanine Transaminase/analysis ; Antibodies, Antinuclear/blood ; Aspartate Aminotransferases/analysis ; Bilirubin/blood ; Female ; Graves Disease/complications/*diagnosis/drug therapy ; Hepatitis, Autoimmune/complications/*diagnosis/drug therapy ; Humans ; Immunoglobulins, Thyroid-Stimulating/blood ; Liver/enzymology/metabolism/pathology ; Prednisolone/therapeutic use ; Steroids/therapeutic use ; Thyrotropin/blood

Systemic lupus erythematosus (SLE) is a multisystem ic inflammatory disorder mediated by autoantibodies and immune complexes that manifests with a variety of symptoms. Lupus enteritis is a serious complication of SLE and carries a high mortality rate, however the diagnosis is not easy for there are no specific clinical manifestations and laboratory findings. Lupus enteritis usually involves the mesenteric arteries causing ischemic changes of the small and large bowels, and yet rarely involves the rectum. Here, we report a case of a 26-year-old female lupus enteritis patient who presented with atypical abdominal pain. Early diagnosis was made by abdominal pelvic computed tomography (CT) scan, which showed extensive involvement of lupus enteritis from proximal small bowel to rectum. She recovered after being treated with high dose steroid therapy.
Abdominal Pain ; Adult ; Antigen-Antibody Complex ; Autoantibodies ; Diagnosis ; Early Diagnosis ; Enteritis* ; Female ; Humans ; Lupus Erythematosus, Systemic ; Mesenteric Arteries ; Mortality ; Rectum*

BACKGROUND/AIMS: The CHADS2 scoring system has been widely used to stratify thromboembolic risk associated with atrial fibrillation. Chronic kidney disease (CKD) is associated with increased risk of stroke in patients with atrial fibrillation (AF) but has not yet been included in risk-scoring systems. We analyzed the difference in thromboembolic risk of patients with AF and a moderate risk of stroke according to the presence of CKD. METHODS: Of 1,952 patients with AF, 451 with a CHADS2 score of 1 were divided into two groups according to the presence of CKD, and thromboembolic events were analyzed. Each group was further classified by the antithrombotic regimen used: warfarin or aspirin. RESULTS: Of the 451 patients, 94 with CKD had a significantly higher risk for thromboembolic complications than the 357 patients without CKD (hazard ratio [HR], 3.630; 95% confidence interval [CI], 1.565-8.422; p = 0.003). Patients with CKD who were on aspirin had a higher risk for thromboembolic events than those on warfarin (HR, 5.203; 95% CI, 1.056-25.633, p = 0.043). However, in patients without CKD, the aspirin group did not have a higher risk of thromboembolic events than the warfarin group (HR, 0.803; 95% CI, 0.225-2.867, p = 0.735). CONCLUSIONS: In Korean patients with AF and a CHADS2 score of 1, CKD may be an independent thromboembolic risk factor. In patients with CKD, warfarin may be superior to aspirin for lowering thromboembolic risk.
Aspirin ; Atrial Fibrillation ; Humans ; Renal Insufficiency, Chronic ; Risk Factors ; Stroke ; Thromboembolism ; Warfarin

A 38-year-old man, who underwent a second kidney transplantation (KT), was admitted because of antibody-mediated rejection (AMR) complicated by BK virus-associated nephropathy (BKVAN). He was placed on hemodialysis at the age of 24 years because of membranoproliferative glomerulonephritis. At the age of 28 years, he underwent a living donor KT from his father; however, 1 year after the transplantation, he developed a recurrence of the primary glomerular disease, resulting in graft failure 2 years after the first KT. Ten years later, he received a deceased-donor kidney with a B-cell-positive-cross-match. He received 600 mg of rituximab before the KT with three cycles of plasmapheresis and immunoglobulin (0.5 g/kg) therapy after KT. During the follow-up, the first and second allograft biopsies at 4 and 10 months after KT revealed AMR with a recurrence of primary glomerular disease that was reclassified as C3 glomerulonephritis (C3GN). He received a steroid pulse, rituximab, plasmapheresis, and immunoglobulin therapies. The third allograft biopsy demonstrated that the BKVAN was complicated with AMR and C3GN. As the azotemia did not improve after repeated conventional therapies for AMR, one cycle of bortezomib (1.3 mg/m²×4 doses) was administered. The allograft function stabilized, and BK viremia became undetectable after 6 months. The present case suggests that bortezomib therapy may be applicable to patients with refractory AMR, even in cases complicated with BKVAN.
Adult ; Allografts ; Azotemia ; Biopsy ; BK Virus ; Bortezomib* ; Fathers ; Follow-Up Studies ; Glomerulonephritis* ; Glomerulonephritis, Membranoproliferative ; Graft Rejection ; Humans ; Immunization, Passive ; Immunoglobulins ; Kidney ; Kidney Transplantation ; Living Donors ; Plasmapheresis ; Recurrence ; Renal Dialysis ; Rituximab ; Transplants ; Viremia

Purpose: Alpha-fetoprotein (AFP) is a prognostic marker for hepatocellular carcinoma (HCC). We investigated the prognostic value of AFP levels in patients who achieved complete response (CR) to transarterial chemoembolization (TACE) for HCC. Materials and Methods: Between 2005 and 2018, 890 patients with HCC who achieved a CR to TACE were recruited. An AFP responder was defined as a patient who showed elevated levels of AFP (>10 ng/mL) during TACE, but showed normalization or a >50% reduction in AFP levels after achieving a CR. Results: Among the recruited patients, 569 (63.9%) with naïve HCC and 321 (36.1%) with recurrent HCC after complete resection were treated. Before TACE, 305 (34.3%) patients had multiple tumors, 219 (24.6%) had a maximal tumor size >3 cm, and 22 (2.5%) had portal vein tumor thrombosis. The median AFP level after achieving a CR was 6.36 ng/mL. After a CR, 473 (53.1%) patients experienced recurrence, and 417 (46.9%) died [median progression-free survival (PFS) and overall survival (OS) of 16.3 and 62.8 months, respectively]. High AFP levels at CR (>20 ng/mL) were independently associated with a shorter PFS [hazard ratio (HR)=1.403] and OS (HR=1.284), together with tumor multiplicity at TACE (HR=1.518 and 1.666, respectively). AFP non-responders at CR (76.2%, n=359 of 471) showed a shorter PFS (median 10.5 months vs. 15.5 months, HR=1.375) and OS (median 41.4 months vs. 61.8 months, HR=1.424) than AFP responders (all p=0.001). Conclusion High AFP levels and AFP non-responders were independently associated with poor outcomes after TACE. AFP holds clinical implications for detailed risk stratification upon achieving a CR after TACE.