1. 속쓰림으로 의뢰된 45 세 유방암 환자 대한소화기내시경학회 2008 년 12 월 2 일 서울아산병원 이정훈

2. Present illness  3 년전 : Rt. Breast cancer Breast conserving operation Post-op RT & adjuvant chemotherapy  2 달전 : both inguinal mass, weight loss, myalgia, chill  1 달전 : skin rash (both proximal L/E & trunk) 인근병원 피부과 : 대증적 치료 이즈음부터 epigastric soreness

3. PET (metastasis w/u) Lt. inguinal LN & mass excisional Bx.: reactive hyperplasia

4. Past Medical History DM/HTN/Tbc./Hepatitis (-/-/-/-) Breast cancer op. + CTx. + RTx. Social History alcohol (-) smoking (-) current medication (-) recent travel experience (including overseas) (-) Family History unremarkable

5. Review of systems General: weight loss (-) febrile sense(+) fatigue (-) Skin: pruritus (-) rash (-) petechia(-) Head & neck: headache (-) otalgia (-) blurred vision (-) Respiratory: dyspnea (-) cough/sputum (-/-) Cardiovascular: chest pain(-) orthopnea (-) palpitation (-) Gastrointestinal: A/N/V/D/C (-/-/-/-/-) Genitourinary: urgency (-) frequency (-) flank pain (-) Musculoskeletal: myalgia (+) arthralgia (-)

6. Physical examination V/S: 130/80 mmHg - 70/min - 18/min - 36.7°C General: chronically ill looking appearance, alert HEENT: not pale conjunctivae, cervical L/N(-) Pulmonary: Clear to auscultation in R&L, crackle(-) CV: S1/S2 normal, no murmurs, regular rhythm Abdomen: soft and flat normoactive bowel sound tenderness (-), rebound tenderness(-) palpable mass(-), hepatomegaly (-), splenomegaly (-) Back & Extremities: pretibial pitting edema(-/-) CVA tenderness (-/-)

7. Initial laboratory data CBC: WBC 4,100/mm 3 Hb 13.2 g/dl PLT 147 K/mm 3 (neutrophil 40.3% lymphocyte 11.0%, monocyte 13.3%) LFT : AST/ALT 26 / 14 IU/L ALP 100 IU/L T-Bil 0.8 mg/dL Protein/Albumin 7.9 / 4.3 mg/dL Ca/P 9.3 / 3.8 mg/dL BUN/Cr: 15 / 0.7 mg/dL

8. Problem list #1. Epigastric soreness #2. s/p breast cancer with RTx. & CTx. #3. Both inguinal mass: reactive hyperplasia #4. Skin rash

9. EGD #1 (initial)

12. GI OPD (1)  3 년전 : Rt. Breast cancer Breast conserving operation Post-op RT & adjuvant chemotherapy  4 달전 : 남편과 성관계  4 달전 : 남편 요로염 증상  2 달전 : both inguinal mass, weight loss, myalgia, chill  2 달전 : 남편 syphilis 진단  1 달전 : skin rash (both proximal L/E & trunk) 인근병원 피부과 : 대증적 치료 이즈음부터 epigastric soreness  입원전 : 인근 병원 피부과에서 매독, AIDS 검사 음성 판정

13. GI OPD (2) O) VDRL : 1:32 reactive TPHA : reactive A)r/o Gastric syphilis P) EGD

14. EGD #2 (GI OPD)

17. EGD #3 ( 치료 2 달후 ) Diagnosis: gastritis syphilis

18. Other AMC cases - 1 25 세 남자, 외부병원 위내시경에서 AGC 의심 3 개월 전 피부와 성기에 발진 혈청 VDRL 1:32, FTA-ABS: reactive

19. Other AMC cases - 2 49 세 남자, 외부병원에서 MALT lymphoma 의심 3 개월 전 전신 발진 혈청 VDRL 1:64, FTA-ABS: reactive

20. Other AMC cases - 3 45 세 여자, 외부병원에서 위암 의심 Silver stain (-)

21. Other AMC cases - 4 32 세 남자, epigastric pain 으로 ER 방문 1 개월 전 성기 궤양 혈청 VDRL 1:64, FTA-ABS: reactive

22. 감사합니다

23. Gastric syphilis  Various endoscopic findings Mucosal erosions Rugal hypertrophy Shallow, geographic ulcers mimicking MALT lymphoma or other lymphoma large, irregular ulcers mimicking cancer Ulcer perforation Gastric outlet obstruction Linitis plastica appearance Ann Intern Med 1992 Feb 15;116(4): 314-9 Am J Gastroenterol 1994 Dec;89(12): 2227-9

24. Serologic Test  Non-Treponemal Test : VDRL, RPR  Treponemal Test : FTA-ABS, MHA-TP(TPHA)  False positive : other infection, after vaccination, auto- immune disease, drug abuse, pregnancy, old age  False negative : too early or too late sampling, too high titer (prozone reaction) PrimarySecondaryLatent VDRL, RPR60~80 %99~100 %70~90 % FTA-ABS80~95 %99~100 %96~100 % MHA-TP70~90 %99~100%96~100 % Courtesy of KW Jung