Leukemoid reaction refers to reactive and excessive leukocytosis with a white blood cell count of more than 50,000 cells/mm3 in the absence of myeloproliferative neoplasm and has usually been described in response to inflammation, severe infection, malignancies, hemorrhage, acute hemolysis, or bone marrow stimulants. In contrast, urothelial cell carcinoma is rarely associated with leukemoid reaction, with few cases reported over the past few years. Here, we report a case of an invasive Urothelial carcinoma of a 63 year old patient presenting with terminal dysuria and excessively elevated and persisting leukocytosis accompanied by rapid tumor progression and deteriorating clinical status. For urothelial cell carcinoma patients exhibiting a leukemoid reaction, removal of the inciting tumor is the definitive treatment. Though placing of urethral catheter and resection of the bladder tumor alleviated the worsening renal status and terminal dysuria on the index patient, the patient still had multiple persistent febrile episodes throughout the course, accompanied by leukocytosis with predominant mature looking neutrophils, and a left shift. Extremely persistent leukocytosis appears to be associated with poor prognosis even after surgical resection and extensive medical management.

Ovarian vein thrombosis (OVT) is a rare disease with complications that can be life-threatening. An ovarian vein thrombus in a gestational trophoblastic neoplasia (GTN) is an extremely rare condition that has not been previously reported in the literature. We report the case of a 23-year-old woman who presented with symptoms of amenorrhea for 15 weeks and 6 days along with intermittent lower abdominal pain. She was diagnosed with a hydatidiform mole, and a metastatic workup was scheduled. Abdominal computed tomography showed a right ovarian vein thrombus. She received methotrexate chemotherapy combined with oral anticoagulants. Complete radiological remission was obtained. During the 12-month follow-up period, no disease progression or recurrence was noted. Early recognition and detection of the condition are of the utmost importance. The differential diagnosis of OVT must be considered when there is unexplained abdominal pain, fever, and leukocytosis during the diagnosis and treatment of GTN. A high level of suspicion is required for prompt diagnosis of OVT.
Abdominal Pain ; Amenorrhea ; Anticoagulants ; Diagnosis ; Diagnosis, Differential ; Disease Progression ; Drug Therapy ; Female ; Fever ; Follow-Up Studies ; Gestational Trophoblastic Disease ; Humans ; Hydatidiform Mole ; Leukocytosis ; Methotrexate ; Pregnancy ; Rare Diseases ; Recurrence ; Thrombosis ; Veins ; Venous Thrombosis ; Young Adult

Mycoplasma pneumoniae (MP) is the most common causative agent of community-acquired pneumonia in school-aged children. An 8-year-old boy who had been diagnosed with autism looked severely ill when he presented to our hospital due to dyspnea and lethargy. He had fever and cough 7 days prior to hospitalization. He had signs and symptoms of severe respiratory distress. The percutaneous oxygen saturation was 88% at high oxygen supply. Chest radiography showed diffusely increased opacity with moderate pleural effusion. He was intubated immediately and admitted to the intensive care unit. Under the clinical impression of mycoplasmal pneumonia, intravenous clarithromycin was started. Laboratory findings showed leukocytosis, hepatitis, decreased renal function, and presence of serum MP immunoglobulin (Ig) M (+) IgG (+) and sputum MP polymerase chain reaction (+). On hospital day 2, the patient developed multiple organ failure with acute respiratory distress syndrome (ARDS). Veno-venous extracorporeal membrane oxygenation (ECMO) was performed with continuous renal replacement therapy (CRRT) and was weaned successfully. This is the first reported case of an ARDS due to MP infection complicated by multiple organ failure that was successfully treated with ECMO and CRRT in South Korea.
Autistic Disorder ; Child ; Clarithromycin ; Cough ; Dyspnea ; Extracorporeal Membrane Oxygenation ; Fever ; Hepatitis ; Hospitalization ; Humans ; Immunoglobulin G ; Immunoglobulins ; Intensive Care Units ; Korea ; Lethargy ; Leukocytosis ; Male ; Multiple Organ Failure ; Mycoplasma pneumoniae ; Mycoplasma ; Oxygen ; Pleural Effusion ; Pneumonia ; Pneumonia, Mycoplasma ; Polymerase Chain Reaction ; Radiography ; Renal Replacement Therapy ; Respiratory Distress Syndrome, Adult ; Sputum ; Thorax

OBJECTIVE: This study was conducted to identify the characteristics of early infants with urinary tract infection (UTI) who visited the pediatric emergency department (PED) and to investigate the characteristics of patients with cerebrospinal fluid (CSF) pleocytosis and incidence of bacterial meningitis. METHODS: We retrospectively reviewed the records of UTI infants aged 31 to 90 days presenting at PED whom had lumbar puncture. From September 1, 2014 to August 31, 2017, a total of 225 infants were enrolled. RESULTS: Twenty three patients had CSF pleocytosis. Of these, two patients were positive for CSF enteroviral polymerase chain reaction, while none were positive for bacterial culture. We compared the characteristics of infants with CSF pleocystosis. There were not diffences in sex, vaccination before fever, general condition, peak body temperature, peripheral white blood cell, C-reactive protein, and procalcitonin between two groups. However, in patients with prematurity history, incidence of CSF pleocytosis was high. Four infants hot bacteremia, and organism of these patients was all Escherichia coli. All of them had negative CSF culture and normal CSF findings. CONCLUSION: No febrile early infants with UTI had bacterial meningitis. As a result, we must not do conventional test of CSF in patients with UTI.
Bacteremia ; Body Temperature ; C-Reactive Protein ; Cerebrospinal Fluid ; Emergencies ; Emergency Service, Hospital ; Escherichia coli ; Fever ; Humans ; Incidence ; Infant ; Leukocytes ; Leukocytosis ; Meningitis ; Meningitis, Bacterial ; Polymerase Chain Reaction ; Retrospective Studies ; Spinal Puncture ; Urinary Tract Infections ; Urinary Tract ; Vaccination

Catabacter hongkongensis is an anaerobic gram-positive coccobacillus that was first isolated in Hong Kong. It is infectious and causes high mortality in patients with rare but underlying diseases. Alistipes indistinctus is an anaerobic gram-negative coccobacillus. This bacterium is a common member of the human intestinal microbiota. We report a case of C. hongkongensis and A. indistinctus isolated from blood cultures of a patient with acute appendicitis. A 35-year-old female patient with no specific medical history was admitted to the hospital due to abdominal pain, vomiting, nausea, and diarrhea experienced on the day before admission. On admission, laboratory tests revealed leukocytosis, neutropenia, and elevated C–reactive protein and procalcitonin levels. Following an abdominal computed tomography showing acute appendicitis with suspected perforation, emergency surgery was performed. Growth was observed in two anaerobic blood culture bottles after four days. After further culturing of the bacteria on Brucella Blood Agar, two types of bacteria were obtained. The two bacterial isolates, one gram-positive and one gram-negative, were unable to be identified using matrix assisted laser desorption ionization-time of flight mass spectrometry (MALDI-TOF MS). Thus, 16S rRNA gene sequence analysis was performed, resulting in identification of the bacteria as C. hongkongensis and A. indistinctus. The patient was administered antibiotics and discharged two days after surgery. Although MALDI-TOF MS enables fast and accurate identification of bacteria, C. hongkongensis and A. indistinctus were not listed in the spectral library, and 16S rRNA gene sequence analysis was useful for identifying the two bacteria.
Abdominal Pain ; Adult ; Agar ; Anti-Bacterial Agents ; Appendicitis ; Bacteria ; Brucella ; Diarrhea ; Emergencies ; Female ; Gastrointestinal Microbiome ; Genes, rRNA ; Hong Kong ; Humans ; Leukocytosis ; Mass Spectrometry ; Mortality ; Nausea ; Neutropenia ; Sequence Analysis ; Vomiting

OBJECTIVE: This study was designed to evaluate hematological disorders and the orchestrating roles of hepcidin and IL-6 in rat models of thioacetamide (TAA) and carbon tetrachloride (CCl4) hepatotoxicity. METHODS: Rats were intraperitoneally injected with TAA (10 mg/100 g rat weight dissolved in isosaline) or CCl4 (100 μL/100 g rat weight diluted as 1:4 in corn oil) twice weekly for eight consecutive weeks to induce subchronic liver fibrosis. Blood and tissue samples were collected and analyzed. RESULTS: CCl4 but not TAA significantly decreased the RBCs, Hb, PCV, and MCV values with minimal alterations in other erythrocytic indices. Both hepatotoxins showed leukocytosis, granulocytosis, and thrombocytopenia. By the end of the experiment, the erythropoietin level increased in the CCl4 model. The serum iron, UIBC, TIBC, transferrin saturation%, and serum transferrin concentration values significantly decreased, whereas that of ferritin increased in the CCl4 model. TAA increased the iron parameters toward iron overload. RT-PCR analysis revealed increased expression of hepatic hepcidin and IL-6 mRNAs in the CCl4 model and suppressed hepcidin expression without significant effect on IL-6 in the TAA model. CONCLUSION These data suggest differences driven by hepcidin and IL-6 expression between CCl4 and TAA liver fibrosis models and are of clinical importance for diagnosis and therapeutics of liver diseases.
Animals ; Blood Chemical Analysis ; Carbon Tetrachloride ; toxicity ; Hepcidins ; pharmacology ; Injections, Intraperitoneal ; Interleukin-6 ; pharmacology ; Iron ; blood ; metabolism ; Leukocytosis ; chemically induced ; therapy ; Liver Cirrhosis ; chemically induced ; therapy ; Male ; Rats ; Thioacetamide ; toxicity ; Thrombocytopenia ; chemically induced ; therapy ; Transferrin ; metabolism

To analyze the clinical and endoscopic features of colonic anisakiasis. A retrospective chart review of 20 patients with colonic anisakiasis, who were diagnosed by colonoscopy at 8 hospitals between January 2002 and December 2011, was performed. Patients’ mean age was 53.6±10.74 years. Seventy percent patients were men. Acute abdominal pain was a common symptom that mostly developed within 48 hr after the ingestion of raw fish, and which lasted for 1–28 days. Sixty percent patients had ingested raw fish before the diagnosis of colonic anisakiasis and 40% patients were incidentally found to have colonic anisakiasis during the screening colonoscopies. Leukocytosis and eosinophilia were each found in 20% of the patients. In all patients who underwent colonoscopy, the worms were removed with biopsy forceps, except in 1 case, and a definite diagnosis of anisakiasis was made. In some cases of colonic anisakiasis, colonoscopy may be helpful in the diagnosis and treatment to avoid surgical intervention.
Abdominal Pain ; Anisakiasis ; Biopsy ; Colon ; Colonoscopy ; Diagnosis ; Eating ; Eosinophilia ; Humans ; Korea ; Leukocytosis ; Male ; Mass Screening ; Retrospective Studies ; Surgical Instruments

Hyperleukocytosis (HL), defined by a peripheral white blood cell (WBC) count exceeding 100,000/mm³, is occasionally observed in childhood acute leukemia. The increased viscosity in the micro-circulation by HL and the interaction between the leukemic blasts and endometrium of blood vessels sometimes result in leukostasis. Leukostasis can incur life-threatening manifestations, such as respiratory distress, brain infarction and hemorrhage, and renal failure, needing an emergency care. Although early stage of leukostasis is difficult to detect due to nonspecific manifestations, an emergency care is mandatory because leukostasis can proceed to a fatal course. Initial management includes an aggressive fluid therapy that can reduce WBC count, and prevent other metabolic complications implicated by HL. Packed red blood cells should be judiciously transfused because it increases blood viscosity. Conversely, transfusion of platelet concentrates or fresh frozen plasma, which does not affect blood viscosity, is recommended for prevention of hemorrhage. To reduce tumor burden, leukapheresis or exchange transfusion is commonly performed. However, the efficacy is still controversial, and technical problems are present. Leukapheresis or exchange transfusion is recommended if WBC count is 200,000–300,000/mm³ or more, especially in acute myelocytic leukemia, or manifestations of leukostasis are present. In addition, early chemotherapy is the definite treatment of leukostasis.
Blood Platelets ; Blood Vessels ; Blood Viscosity ; Brain Infarction ; Disease Management ; Drug Therapy ; Emergencies ; Emergency Medical Services ; Emergency Service, Hospital ; Endometrium ; Erythrocytes ; Female ; Fluid Therapy ; Hemorrhage ; Leukapheresis ; Leukemia ; Leukemia, Myeloid, Acute ; Leukocyte Disorders ; Leukocytes ; Leukocytosis ; Leukostasis ; Plasma ; Renal Insufficiency ; Tumor Burden ; Viscosity

PURPOSE: Though prompt diagnosis to minimize symptom duration (SD) is highly associated with organ salvage in cases of testicular torsion (TT), SD is subjective and hard to determine. We thus investigated the clinical implications of systemic inflammatory responses (SIRs) as potential surrogates of SD to improve testis survival. MATERIALS AND METHODS: Sixty men with TT that underwent immediate operation among orchiectomy and orchiopexy following a visit to a single emergency department were retrospectively enrolled. Mandatory laboratory tests conducted included neutrophil, lymphocyte, and platelet counts. RESULTS: Mean age and SD was 15.7±3.7 years and 8.27±4.98 hours, respectively. Thirty-eight (63.3%) underwent orchiectomy and the remaining 22 underwent orchiopexy. Leukocytosis (p=0.001) and neutrophil-lymphocyte ratio (NLR, p < 0.001) were significantly lower in the orchiopexy group as was SD (3.27±1.88 vs. 11.16±3.80, p < 0.001). Although multivariate model showed that the only single variable associated with receipt of orchiopexy was SD (odds ratio [OR]=0.259, p < 0.001), it also revealed NLR as a sole SIR associated with SD (B=0.894, p < 0.001). While 93.3% with a SD of within 3 hours underwent orchiopexy, only 26.6% of affected testes were preserved between 3 to 12 hours (n=30). When multivariable analysis was applied to those with window period, NLR alone predicted orchiopexy rather than orchiectomy (p=0.034, OR=0.635, p=0.013). The area under curve between SD (0.882) and NLR (0.756) was similar (p=0.14). CONCLUSIONS: This study showed NLR independently predicted testis survival by proper surgical correction particularly for patients with marginally delayed diagnosis, which suggest the clinical usefulness for identifying candidates for orchiopexy in emergency setting.
Area Under Curve ; Delayed Diagnosis ; Diagnosis ; Emergencies ; Emergency Service, Hospital ; Humans ; Inflammation ; Leukocytosis ; Lymphocytes ; Male ; Neutrophils ; Orchiectomy ; Orchiopexy ; Platelet Count ; Retrospective Studies ; Spermatic Cord Torsion* ; Symptom Assessment ; Testis

BACKGROUND: Acute necrotizing encephalopathy (ANE) is a rare, but potentially life threatening neurological condition in children. This study aimed to investigate its clinical spectrum, diagnostic and therapeutic dilemma, and prognosis. METHODS: Twelve children with ANE were included in the study. The diagnosis was made by clinical and radiological characteristics from January 1999 to December 2017 and their clinical data were retrospectively analyzed. RESULTS: A total of 12 children aged 6 to 93 months at onset (5 male: 7 female) were evaluated. The etiology was found in 4 of them (influenza A, H1N1; coxsackie A 16; herpes simplex virus; and RANBP2 gene/mycoplasma). The most common initial presentations were seizures (67%) and altered mental status (58%). The majority of the subjects showed elevation of aspartate aminotransferase/alanine aminotransferase with normal ammonia and increased cerebrospinal fluid protein without pleocytosis. Magnetic resonance imaging revealed increased T2 signal density in bilateral thalami in all patients, but the majority of the subjects (67%) also had lesions in other areas including tegmentum and white matter. Despite the aggressive immunomodulatory treatments, the long-term outcome was variable. One child and two sisters with genetic predisposition passed away. CONCLUSION: ANE is a distinctive type of acute encephalopathy with diverse clinical spectrum. Even though the diagnostic criteria are available, they might not be watertight. In addition, treatment options are still limited. Further studies for better outcome are needed.
Ammonia ; Aspartic Acid ; Brain Diseases ; Cerebrospinal Fluid ; Child ; Diagnosis ; Genetic Predisposition to Disease ; Humans ; Leukocytosis ; Magnetic Resonance Imaging ; Male ; Prognosis ; Retrospective Studies ; Seizures ; Siblings ; Simplexvirus ; White Matter