1. Medical Grand Round 신장내과 R2 김승민 신이식 환자에서 발생한 감염증 1 례

2. 10938705 M/48 전 O 환 adm. 2011.01.10 Chief Complaint Uncontrolled DM o/s) 내원 한달전 Present illness 1990 년에 당뇨 처음 진단받았고, 2006 년 8 월 부터 DM ESRD 로 본원 신장내과에서 주 3 회 혈액 투석 치료 받는 환자로 2010 년 12 월 7 일 KTP ( donor 동생 ) 이후 12 월 20 일 퇴원한 자로 신장내과 외래에서 혈당 조절 안되고 지속적으로 Hyperglycemia 소견 보여 혈당 조절 위해 입원함

3. Past Medical History DM / HTN / Pul.TB / hepatitis (+ / + / + / - ) Chronic pancreatitis (1997,2001 ERCP 시행 ) Pneumonia (2001) Pul. Tb (2003.12~ 2004.06  6 개월간 Tb medication) Extrapul. Tb ( 2009.12 ~ 2010.09  9 개월간 Tb medication) OPHx (+) 2006.09.11 AVF, Lt 2010.12.7 KTP (donor 동생 ) Drug Hx(+) Tacrolimus 2.0mg bid, Myfortic acid 720mg bid, Solondo 20mg Madipine 10mg qd Levemir 18 IU, Novorapid 6-6-18 IU History

4. Personal History Alcohol (-): 17 년전 stop ( 이전 daily 소주 0.5 병 ) Smoking (-): ex –smoker ( 0.5 P / day x 20yrs = 10 p/y) Occupation : 건축업 / 학력 : 초졸 Family History HTN DM ESRD

5. PMHx Chronic pancreatitis d/t multiple stones 1997 년 4 월 2001 년 4 월 Pneumococcal pneumonia cefotaxime + clindamycin sputum : S. Penumoniae 2003 년 11 월 DM ESRD (stage V)  HD ( 주 3 회 시행 ) Pul Tb 진단 TB medication HERZ(2)+ HER(4) 2006 년 08 월

6. PMHx ( ExtraPul Tb. 2009.11.20-2010.09.20 ) 2009.12.21 Liver Bx  Chronic inflammation  Tb tissue PCR (-) 2009.12.23  Tb medication 시작함

7. PMHx (ExtraPul Tb. 2009.11.19-2010.09.20) 2009/11/192010/6/252010/11/12 Tb medication ( INH 300mg/RFP 450mg/EMB 800mg EOD) 2009/12/24~ 2010/9/20 -> total (9 Mo) 2010/12/10 KTP

8. Review of System General General Fatigue(-) Febrile sensation(-) Chill(-) Wt. Loss (-) Skin Skin Rash(-) Pigmentation(-) Itching(-) H&N H&N Headache(-) Sore throat(-) Hearing disturbance(-) Rhinorrhea(-) Nasal Obx.(-) Post. neck pain(-) Respiratory Respiratory Cough(-) Sputum(-) Tachypnea(-) Dyspnea(-) Hemoptysis(-) Cardiac Cardiac Chest pain(-) Orthopnea(-) Palpitation(-)

9. Review of System G-I G-I Anorexia(-) Abd. discomfort (-) Nausea(-) Vomiting(-) Abd. pain(-) Diarrhea(-) Melena(-) Hematochezia(-) Constipation(-) Renal Hematuria(-) dysuria(-) frequency(-) B/Ext. Upper back pain(-) Lower back pain (-) Neurology Sensory Motor 100 ⅤⅤ Ⅴ Ⅴ

10. Physical Examination V/S 110 / 70 mmHg – 66/min – 20/min – 36.0 °C height : 163.5 cm weight : 47 kg BMI : 17.6 kg/m 2 General Appearance Alert consciousness Chronic ill-looking appearance Head & Neck No LN enlargement No neck vein engorgement No thyroid enlargement No neck stiffness PI (-) PTH (-/-) No papilledema Eye & ENT Isocoric pupil with PLR(++/++) Pinkish conjunctiva with Clear sclera

11. Physical Examination Chest Clear breathing sound without crackle or wheezing Regular heart beat without murmur Abdomen Soft & distended abdomen Normoactive bowel sound Tenderness(-) Rebound tenderness(-) Shifting dullness(-) No Hepatosplenomegaly Back & Ext. CVA tenderness (-/-) Pretibial pitting edema(-/-)

12. Initial Lab. Findings CBC/DC 9,640/mm 3 – 11.2 g/dL – 33.2% - 249,000/mm 3 (Seg. 67.8 %) INR / aPTT 0.86 / 28.3 (sec) Chemistry TB/ DB 0.43 / 0.06 mg/dL Prot/ Alb 6.70 / 3.8 g/dL AST/ ALT 15 / 31 U/L ALP/ GGT 128 / 47 U/L BUN/ Cr 10 / 0.6 mg/dL Na/K/ Cl 133 / 4.1 / 100 mmol/L Ca/ P / Mg 8.9 / 1.3 / 1.9 mg/dL CRP 0.98 mg/dL glucose 111 mg/dL

13. CXR

14. EKG

15. Initial Problem Lists #1. Cavitary lung lesion on RUL #2. uncontrolled DM #3. KTP status #4. HTN

16. Diagnostic & Therapeutic Plans #1. Cavitary lung lesion on RUL d/t r/o Tb re-activation d/t r/o fungal infection d/t r/o lung abscess Diagnostic plan Chest CT/ Abdomen CT blood Cx, sputum exam, serologic marker, Aspergillus Ag. Bronchoscopy / CT guided Bx if needed surgical resection Therapeutic plan Tb medication/ antibiotics / anti-fungal agent / surgical resection

17. #2. Uncontrolled DM Therapeutic plan insulin 용량조절 #3 DM ESRD s/p KTP (2010.12.07) Therapeutic plan immunosuppresant (steroid, MMF, Tacrolimus) 조정 #4 HTN Therapeutic plan madipine 20mg qd 유지 Diagnostic & Therapeutic Plans

18. 2010.12.20 2011.01.11 CXR (HD#1)

19. Chest CT/abd. CT (HD #2)

20. Bronchoscopy (HD #4) BAL 2011.01.13 CxNo growth AFB Negative TB Cx Negative Tb PCR Negative Direct smear Not found Fungal Cx No growth G stain A few G rod Washing cytology Negative

21. Serologic marker (HD #4) blood Blood culture No growth Aspergillus Ag Negative P. Carinii Stain Negative EBV VCA IgM Negative CMV IgM Antigenemia Negative CMV PCR Negative Herpes IgM Negative respiratory virus PCR Negative sputum Cx no growth G stain a few AFB Negative TB Cx Negative fungal Cx no growth direct smear Negative

22. CT guided Bx (HD #5) tissue AFB Negative Tb culture Pending Fungus Cx No Growth Cx No Growth Tb PCR Negative Bx Acute inflmmation

23. Wedge resection by VATS(HD #15) Tissue 2011.1. 24 Cx No growth Tb culture No growth Tb PCR Negative fungal Cx No growth G stain Negative PUS 2011.1. 24 CxNo growth Tb cultureNo growth Tb PCRNegative fungal CxNo growth G stainNegative

24. Pathology HE stain PAS Bx : mucormycosis

25. Pathology GMS Bx : mucormycosis

26. Clinical course VATS CT –guided Bx AmB 25mg/d (D4) LAmB 3mg/kg (D7) LAmB 4mg/kg (D23) Total 5.0g Bronchoscopy Mucormycosis

27. Clinical course Mucormycosis Anti fungal Tx 2011.01.262011.02.07 F.U CT 2011.03.02 Discharge F.U CT C-Tube insertion 2011.03.15

28. Immunesuppresant Tacr1.5/1.5mg 2011.01.11 Cavitary lesion 2011.01.26 Antifungal agent MMF PDL Tacr2/2mg 720/720mg 20mg 15mg 10mg 2011.02.07 Fu CT 360mg bid 5mg Cs A200mg 300mg 360mg bid Discharge 2011.03.15

29. Final diagnosis  #1. pulmonary mucormycosis s/p wedge resection  #2. s/p KTP, DM ESRD  #3. uncontrolled DM  #4. HTN