1. 두통을 주소로 내원한 37 세 남자 소화기내과 R1 김다래 / Prof. 이창균

2. 10981995 박 O 규 (M/37) Adm 2012.06.08 주소 두통 onset time) 내원 1 주일 전 현병력 17 년 전 Crohn's disease 진단받고 약물치료하며 지내던 자로 내원 7 개월 전부터 어깨, 목, 손목 등의 전신통증 발생하여 수 차례에 걸쳐 타병원 진료받았으나 증세 호전 없어 자세한 검사 및 치료 위해 본원 소화기내과 외래 방문하였으며 전신통증에 관해 류마티스 내과 협진 진료받으며 약물 치료하며 지내던 중 갑작스런 두통 발생하여 입원함

3. 과거력 DM/HTN/Hepatitis/Tbc (-/-/-/-) Crohn's disease(+) : 1995 년 진단받고 현재 p.o med 중 Op Hx (+) : 1989 년, 1992 년 Fistulectomy d/t perianal fistula 개인력 Smoking : ex-smoker 1 갑 / 일 X 10 년 =10 갑년 Alcohol (-) 가족력 (-)

4. 199219952005.92007.42009.52012.22012.4 IG 외래 1989 Fistulotomy #1 Crohn’s Disease Fistulotomy #2 2002.3 *steroid Azathioprine 5-ASA Azathioprine 150mg qd Mesalazine 1500mg bid 약제 복용력 2012.6 입원 *steroid

5. Review of system General febrile sensation(-) chills(-) body weight loss(-) Skin rash(-)itching(-)pigmentation(-) HEENT headache(-)sore throat(-)hoarseness(-) Respiratorycough(-)sputum(-)dyspnea(-) Cardiac chest pain(-)palpitation(-)syncope(-) GIA/N/V/D/C(-/-/-/+/-)abdominal pain(-) hematochezia(-)melena(-)hematemesis(-) GUflank pain(-)hematuria(-)dysuria(-) Musculoskeletal weakness(-)pain(+)numbness(-) Nerve system dizziness(-)sensory loss(-)motor weakness(-) Location : posterior neck, shoulder, back, hand, wrist, knee, foot, ankle Character : 불에 타들어가듯이 아프다 온몸이 쑤시는 것 같다. 죽을 것 같다 ! Duration : on-going pain VAS : 5 점 Ass Sx : fever(-) morning stiffness(-)

6. Physical examination Vital sign 110/70mmHg - 78/min - 18/min - 36.8°C Height : 165cm Weight : 60 kg BMI : 22kg/m 2 General Alert mentality Chronic- ill looking appearance HEENT Isocoric pupil c PLR (++/++) Cervical LN enlargement (-) PI(-) PTH(+/+) Neck stiffness(-) Thorax Symmetrical chest expansion Clear breathing sound s rale Regular heart beat s murmur

7. Physical examination Abdomen Soft & flat abdomen Normoactive bowel sound Abdominal Td/rTd(-/-) Muscle guarding(-) Back & Ext Pretibial pitting edema(-/-) CVA Td(-/-) Kernig’s sign(-) Brudzinski sign(-) Td(+) : posterior neck, back, shoulder, wrist, ankle both Neurology Motor Sensory 100 ⅤⅤ ⅤⅤ

8. Initial Lab Findings CBC/DC 5,470/mm² - 14.5g/dL – 43.5% - 233K (seg. 65.1%) PT(INR)13.0 sec (0.96) aPTT36.8 sec Chemistry Prot/Alb6.4/3.9 g/dL TB/DB1.57/0.35 mg/dL AST/ALT33/30 IU/L ALP/GGT103/358 IU/L BUN/Cr17/0.8 mg/dL Na/K/Cl140/4.3/104 mEq/L Ca/P/Mg9.3/4.4/2.1 mg/dL LD/CK349/33 U/L CRP<0.3 mg/dl U/A Protein (-) Blood (-) Nitrite (-) Glucose (–) Sediment exam : RBC 0-1/HPF, WBC 0-1/HPF

9. Chest X-ray

10. EKG

11. Initial problem list #1. Headache #2. Generalized myalgia #3. Known Crohn's disease

12. Initial assessment & plan #3. Known Crohn’s dsease A2,L3,B1 S) abdominal pain(-) diarrhea(+) hematochezia(-) O) Montreal classification of Crohn’s disease Crohn's disease activity index (CDAI) Colonoscopy

13. Crohn's disease activity index (CDAI) √ √ √ 14 21 1 Total 183 147 전신 쑤시는 듯한 통증, 가끔씩 죽고 싶을 정도 !

14. Initial assessment & plan #3. Known Crohn’s dsease A2,L3,B1 S) abdominal pain(-) diarrhea(+) hematochezia(-) O) Montreal classification of Crohn’s disease Crohn's disease activity index (CDAI) Colonoscopy Very poor general condition ? endoscopic remission state ! 전신통증 때문 !

15. Initial assessment & plan #3. Known Crohn’s dsease A2,L3,B1 S) abdominal pain(-) diarrhea(+) hematochezia(-) O) Montreal classification of Crohn’s disease Crohn's disease activity index (CDAI) Colonosocpy A) mildly to moderately active Crohn’s disease P) Therapeutic plan 현재 medication 유지 –Azathioprine 150mg qd –Mesalazine 1500mg bid

16. Initial assessment & plan #2. Generalized myalgia S) Posterior neck, shoulder, arm, back, wrist, ankle both A) r/o C-spine, L-spine radiculopathy r/o Peripheral neuropathy r/o Peripheral arthritis r/o Fibromyalgia ….………………………….…………...…. ….…….…..……………. …… ….…… … ….…………………… … FMS criteria LAB : serologic marker X-ray, MRI, bone scan EMG

18. Initial assessment & plan #2. Generalized myalgia S) Posterior neck, shoulder, arm, back, wrist, ankle both A) r/o C-spine, L-spine radiculopathy r/o Peripheral neuropathy r/o Peripheral arthritis r/o Fibromyalgia ….………………………….…………...…. ….…….…..……………. …… ….…… … ….…………………… … FMS criteria LAB : serologic marker X-ray, MRI, bone scan EMG : within normal range

19. Initial assessment & plan #2. Generalized myalgia S) Posterior neck, shoulder, arm, back, wrist, ankle both A) r/o C-spine, L-spine radiculopathy r/o Peripheral neuropathy r/o Peripheral arthritis r/o Fibromyalgia ….………………………….…………...…. ….…….…..……………. …… ….…… … ….…………………… … FMS criteria LAB : serologic marker X-ray, MRI, bone scan EMG LAB (2012.4.20) IgG 705mg/dL IgA 33mg/dL Anti-CCP Ab (-) RF (-) ANA non-reactive C-ANCA (-) P-ANCA (-)

20. Initial assessment & plan #2. Generalized myalgia S) Posterior neck, shoulder, arm, back, wrist, ankle both A) r/o C-spine, L-spine radiculopathy r/o Peripheral neuropathy r/o Peripheral arthritis r/o Fibromyalgia ….………………………….…………...…. ….…….…..……………. …… ….…… … ….…………………… … FMS criteria LAB : serologic marker X-ray, MRI, bone scan EMG

21. FMS diagnostic criteria 2010 Fibromyalgia 110110 Total 5

22. Initial assessment & plan #2. Generalized myalgia S) Posterior neck, shoulder, arm, back, wrist, ankle both A) Fibromyalgia P) Therapeutic plan IR medication start (2012.4.16-) –Prednisolone 5mg qd –Pregabalin 75mg qd –Nortriptyline 25mg qd –Tramadol/AAP 37.5/325mg bid Gabapentin 100mg bid

23. Initial assessment & plan #1. Headache S) Headache (+) A) r/o tension type headache, much likely r/o brain tumor, less likely r/o meningitis, less likely P) Diagnostic plan Brain CT if needed, Brain MRI If fever, neck stiffness (+) ---> if needed, NR consultation consider diagnostic lumbar puncture Location : bi-temporal area Duration : on-going Character : band like headache Ass Sx : N/V(-/-) Course : crescendo type, much aggravation

24. Multiple metastatic tumors Brain CT 2012.6.8 NS admission for evaluation !

25. Multiple brain abscess Brain MRI 2012.6.9 T2 FLAIRT1WI

26. 2012.6.8 Brain CT CT Metastatic tumor? MRI Multiple brain abscess ? 2012.6.9 Brain MRI

27. Abdomen CT 2012.6.13 No primary tumor !

28. PET-CT 2012.6.13 r/o brain metastasis ? r/o brain abscess ? NO PRIMARY TUMOR !

29. Operative Biopsy 2012.6.15 2012.6.15Biopsy

30. Result Report 2012.6.25 H&E X400CD20 X400 EBVX400 IGH rearrangement Diffuse large B-cell lymphoma EBV (+)

31. Final Diagnosis #1. Diffuse Large B-cell Lymphoma, EBV positive associated with immunosuppression in CD #2. Fibromyalgia #3. Known Crohn’s disease A2,L3,B1

32. 2011.12 뒷 목 통증 발생 연대 세브란스병원 방문 MRI : C-HIVD C3-4-5 진단 Management : 신경 차단술 시행 2012.2 양 어깨, 팔다리 통증 발생 아산병원 마취통증의학과 방문 Management : 진통제 복용, 물리치료 시행 2012.3 허리, 양 무릎, 발목 통증 발생 고려대학교병원 재활의학과 방문 EMG : 이상소견 없음 Management : TPI 시행 → NP 진료권유, 항우울제 복용 Clinical courseClinical course 2012.4 경희의료원 소화기내과 방문 류마티스내과 협진 진료 시작

33. 4/13 4/16 IG IR 6/15 Biopsy GKRS 6/29 Fibromyalgia Crohn’s Disease 7/10 7/168/21 MVPDC#1MVPDC#2 Gabapentin 100mg bid Prednisolone 5mg qd Pregabalin 75mg qd Nortriptyline 5mg qd TRD/AAP 37.5/325mg bid Brain CT Metastatic tumor NR 6/8 6/9 NS admission Brain MRI Brain abscess 6/13 PET-CT Brain abscess ? Metastatic tumor ? 2011.12 월 말 Myalgia 2012.6.17 Confusio n 2012.6 월 초 Headache 6/25 7/3 IH transfer out Whole brain RTx Clinical courseClinical course DLBL, EBV positive ass. with iatrogenic immunosuppression in CD