Case Reports Korean Circulation J 2000;30 10 : Urokinase 정맥주사로치료한재발성폐혈전색전증 1 예 박경창 김지수 김삼 육청미 이상무 정성원 이남호 박대균 Recurrent Pulmonary Thromboembo
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1 Case Reports Korean Circulation J 2000;3010: Urokinase 정맥주사로치료한재발성폐혈전색전증 1 예 박경창 김지수 김삼 육청미 이상무 정성원 이남호 박대균 Recurrent Pulmonary Thromboembolism Treated with Urokinase Kyung-Chang Park, MD, Jee-Soo Kim, MD, Sam Kim, MD, Chung-Mi, Youk, MD, Sang-Mu Lee MD, Sung-Won Jung MD, Nam-ho Lee, MD and Dae-Gyun Park, MD Department of Internal Medicine, College of Medicine, Hallym University, Seoul, Korea ABSTRACT The symptoms and signs of acute pulmonary arteries thrombosis are nonspecific. So clinical suspicion is the most important in the diagnosis. Treatment of pulmonary thromboembolism include anticoagulant, thrombolytic agent, or surgical intervention. We experienced a case of recurrent pulmonary thromboembolism without coagulation defect and any risk factor except old age and obese. Initially we treated with heparin, but clinical symptoms were aggravated. After we changed to urokinase total 330 million IU2 days, the pulmonary arteries obstruction were resolved and clinical symptoms were improved without any complications. So we report this clinical experience with review of articles. Korean Circulation J 2000;3010: KEY WORDSRecurrent pulmonary thromboembolism Urokinase Low-molecular-weight heparin. 서 론 증례 1285
2 1286 Fig. 1. AInitial ECG showed sinus tachycardia, low QRS voltage in limb leads and poor R progression in chest leads. BFollow-up ECG showed normal sinus rhythm and voltage. Initial poor R progression disappeared. Korean Circulation J 2000;3010:
3 Fig. 2. Chest CT with angiography. A Hospital day 3rd (HD #3). This film showed abnormal low density filling defects in right main pulmonary artery (PA), right superior and inferior PA, and left inferior PA. B HD #4. Filling defect in right main PA decreased. C HD #15. Filling defects were not noted except left inferior PA. D After 30 days. Small filling defect in left inferior PA remained. nase 투여 후 1일째) 호흡곤란 및 흉통 등의 증상들이 투여 후 25일째) warfarin 단독요법으로 전환 후 퇴원 호전되기 시작하였다(Fig. 2B). 입원 11일째 warfarin 하였으며 현재 외래에서 추적 관찰하고 있다(Fig. 2D). 을 저용량부터 병용하여 투약하였으며 입원 12일째부 터 양측 폐하부에서 수포음이 들려 입원 15일째(uro- 고 안 kinase 투여 후 12일째) 흉부 전산화 단층촬영 및 혈 관 조영술 재시행을 하였으나 좌하폐동맥을 제외한 다 폐혈전색전증의 흔한 임상증상으로 호흡곤란, 흉통, 른 부위들의 병변들은 전부 소실된 상태였다(Figs. 2C 기침 등이 있으며 임상징후로 빈호흡, 수포음, 빈맥, 제 and 3). 입원 24일째(urokinase 투여 후 21일째) 시행 4심음 및 제2심음의 폐판막음 증가 등이 있으나 이러 한 폐관류 주사에서도 관류결손 보이지 않았으며(Fig. 4) 한 임상증상 및 징후는 비특이적이기 때문에 의심을 하 환자의 증상도 모두 소실되어 입원 28일째(urokinase 지 않으면 조기진단이 어렵다. 특히 심폐질환을 동반한 1287
4 Fig. 3. Chest CT (lung window setting). A HD # 4. Decreased pulmonary vascularities were noted in right upper lung field. B HD # 15. Pulmonary vascularities increased in right upper lung field. Fig. 4. Lung perfusion scan. A Multifocal perfusion defects were noted in both lung field. B HD #24. Abnormal photon defect was not observed. 환자에서는 다른 질환들과의 감별을 필요로 하기 때문 에 임상적 의심이 무엇보다 중요하다. 진단 방법으로 압이 유발되고 이로 인해 우심실 후부하 증가와 우심실 검사실 소견, 심전도, 흉부 방사선 검사, 심초음파 검사, 부전이 발생하면 우심실 박동량 감소, 정맥압의 상승, 나선형 흉부 전산화 단층촬영, 자기공명 영상, 폐 환기 저혈압 등을 초래한다. 이때 심실 중격이 좌측으로 밀 및 관류주사, 폐동맥 조영술 등이 있으며 최근 D-dimer 려 좌심실 박동량 감소와 좌심실 이완기 압력이 증가되 와 심초음파 검사를 조기진단에 이용하고 있으며 폐 환 어 심박출량 감소를 유발한다.4) 폐동맥 조영술에서 기 및 관류주사와 폐동맥 조영술로써 확진을 한다.1-3) 50%이상의 해부학적 폐색을 동반하는 대량의 폐동맥 감별 진단으로 심근 경색, 폐렴, 만성 폐쇄성 폐질환, 기 혈전증인 경우 전신적 저혈압, 저산소혈증, 청색증 등 흉, 울혈성 심부전, 심막염, 천식 등이 있다. 이 나타나며 증상 발현 후 반수 환자에서 30분 이내, 폐혈전색전증에서의 혈역학적 변화는 폐동맥의 폐색 정도와 관련이 있다. 폐동맥 단면적의 감소로 인한 폐 동맥 설압력(wedge pressure)의 증가로 폐동맥 고혈 %에서 1시간 이내, 80%에서 6시간 이내에 사망하 는 것으로 알려져 있다.5) 폐혈전색전증을 유발하는 위험인자로 수술, 외상, 울 Korean Circulation J 2000;30(10):
5 1289
6 요 중심단어 REFERENCES 1) Perrier A. Noninvasive diagnosis of pulmonary embolism. Haematologica ) Stein PD, Hull RD, Pineo GF. The role of newer diagnostic thechniques in the diagnosis of pulmonary embolism. Curr Opin Pulm Med ) Graven T. Massive pulmonary embolism echocardiogrphic diagnosis and thrombolytic therapy. Tidsskr Nor Laegeforen ) Glantz SA, Misbath GA, Moores WY. The pericardium substantially affects the left ventricular diastolic pressure volume relationship in dog. Cir Res 약 5) Soloff LA, Rodmann J. Acute pulmonary embolism clinical. Am Heart J ) Goldhaber SZ. Harrison s principles of internal medicine. 14th ed. The McGraw-Hill Companies1998. p ) Leroyer C, Mercier B, Escoffre M, Ferec C, Mottier D. Factor Leiden prevalence in venous thromboembolism patients. Chest ) Simonneau G, Sors H, Charbonnier B, Page Y, Laaban JP, Azarian R, et al. A comparison of low-molecular-weight heparin with unfractionated heparin for acute pulmonary embolism. N Engl J Med ) Tapson VF. Cecil textbook of medicine. 21th ed. WB Saunders2000. p ) Konstantinides S, Geibel A, Olschewski M, Heinrich F, Grosser K, Rauber K, et al. Association between thrombolytic treatment and the prognosis of hemodynamically stable patients with pulmonary embolism results of a multicenter registry. Circulation ) Konstantinides S, Tiede N, Geibel A, Olschewski M, Just H, Kasper W. Comparison of alteplase versus heparin for resolution of major pulmonary embolism. Am J Cardiol ) Konstantinides S, Geibel A, Kasper W. Submassive and massive pulmonary embolism a target for thrombolytic therapy? Thromb Haemost ) Bottiger BW, Bach A, Bohrer H, Martin E. Acute thromboembolism of the lung. clinical picture-pathology-diagnosis-therapy. Anaesthesist ) Simonneau G. New perspectives for treatment of pulmonary embolism. Haemostasis ) Girard P. Pulmonary embolism. Current aspects of treatment. Presse Med ) Ribeiro A, Lindmarker P, Johnsson H, Juhlin DA, Jorfeldt L. Pulmonary embolism one-year follow-up with echocardiography doppler and five-year survival analysis. Circulation ) Riedel M, Stanek V, Widimsky J, Prerovsky I. Long term follow-up of patients with pulmonary thromboembolismlate prognosis and evaluation of hemodynamic and respiratory data. Chest ) Paraskos JA, Adelstein SJ, Smith RE, Rickman FD, Grossman W, Dexter L, et al. Late prognosis of acute pulmonary embolism. N Engl J Med Korean Circulation J 2000;3010:
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