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Malone MAV, Castillo DAA, Santos HT, Kaur A, Elrafei T, Steinberg L, Kumar A. A systematic review of the literature on localized gastrointestinal tract amyloidosis: Presentation, management and outcomes. Eur J Haematol 2024; 113:400-415. [PMID: 39030954 DOI: 10.1111/ejh.14269] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2022] [Revised: 06/22/2024] [Accepted: 06/25/2024] [Indexed: 07/22/2024]
Abstract
PURPOSE Localized gastrointestinal tract amyloidosis is uncommon and little is known regarding this entity. There is no current standard of care for the management of localized amyloidosis. The objective of this study was to evaluate the characteristics, available treatments, outcomes and surveillance of these patients. METHODS We conducted a systematic review of cases reported in the literature from 1962 to 2021. Patients with gastrointestinal amyloidosis reported in English literature were included in the analysis. We described and summarized the patient's characteristics, treatments, clinical presentations, outcomes and surveillance. RESULTS The systematic review of reported clinical cases included 62 patients. In these patients, the most common site of amyloid deposition was the stomach (42%). The median age of diagnosis is 64.4 years old; there is a 2:1 prevalence among males (63%) to females (37%); abdominal pain is the most common type of presentation (41%), although patients could also be asymptomatic. There is a high curative rate (100%) with resection alone. Among patients treated with a type of systemic therapy, 80% achieved a complete response. The minority of cases reported a type of surveillance post treatment, and among those 62% pursued serial clinical evaluations alone. CONCLUSION To our knowledge, this is the first and largest systematic review of the literature in gastrointestinal tract amyloidosis. This is more common among males and seems to have an excellent curative rate (100%) with surgery alone. Systemic therapy is an option for those with non-resectable amyloidomas. Serial clinical evaluations should be part of the standard surveillance care in these patients.
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Affiliation(s)
| | | | - Heitor Tavares Santos
- Department of Medicine, Division of Internal Medicine, Albert Einstein College of Medicine, Bronx, New York, USA
| | - Anahat Kaur
- Department of Medicine, Division of Oncology and Hematology, Albert Einstein College of Medicine, Bronx, New York, USA
| | - Tarek Elrafei
- Department of Medicine, Division of Oncology and Hematology, Albert Einstein College of Medicine, Bronx, New York, USA
| | - Lewis Steinberg
- Department of Medicine, Division of Oncology and Hematology, Albert Einstein College of Medicine, Bronx, New York, USA
| | - Abhishek Kumar
- Department of Medicine, Division of Oncology and Hematology, Albert Einstein College of Medicine, Bronx, New York, USA
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2
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Cappello M, Barbara G, Bellini M, Consalvo D, Di Sabatino A, Marasco G, Principi M, Savarino EV, Tortora A, Obici L. Identification and management of gastrointestinal manifestations of hereditary transthyretin amyloidosis: Recommendations from an Italian group of experts. Dig Liver Dis 2024; 56:1014-1020. [PMID: 38105149 DOI: 10.1016/j.dld.2023.11.025] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/26/2023] [Accepted: 11/23/2023] [Indexed: 12/19/2023]
Abstract
Gastrointestinal manifestations are common across all hereditary transthyretin amyloidosis (ATTRv) genotypes. However, they are poorly specific, and their recognition as part of ATTRv is difficult, resulting in misdiagnosis with more common conditions. Moreover, delays in diagnosis occur because of fragmented knowledge, a shortage of centers of excellence and specialists dedicated to ATTRv management, and the scarce involvement of gastroenterologists in multidisciplinary teams. A group of Italian gastroenterologists with experience in the management of ATTRv took part in a project aimed at assessing the awareness of ATTRv among the community of Italian gastroenterologists through an online survey and providing education about practical aspects of ATTRv management. Survey results reported low participation, and very few patients with ATTRv were cared for by gastroenterologists. This highlights the need for greater attention to rare diseases in gastroenterology and emphasizes increasing awareness of ATTRv and diagnostic suspicion. Based on the experts' recommendations, a diagnosis of ATTRv should be suspected when at least one of the 'red flags' is detected. Subsequently, it is suggested to promptly ask for genetic testing and exclude a serum and urinary monoclonal protein, even before the detection of amyloid in biopsy samples, particularly in non-endemic areas.
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Affiliation(s)
- Maria Cappello
- Gastroenterology and Hepatology Section, ProMiSe Department, University of Palermo, Piazza delle Cliniche 2, 90127, Palermo, Italy.
| | - Giovanni Barbara
- Department of Medical and Surgical Sciences, University of Bologna, via Massarenti 9, 40138, Bologna, Italy; IRCCS Azienda Ospedaliero-Universitaria di Bologna, Via Albertoni 15, 40138, Bologna, Italy
| | - Massimo Bellini
- Gastroenterology Unit, Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, Via Savi 10, 56126, Pisa, Italy
| | - Danilo Consalvo
- Department of Gastroenterology and Digestive Endoscopy, AORN ``Antonio Cardarelli'', Via Antonio Cardarelli 9, 80131, Napoli, Italy
| | - Antonio Di Sabatino
- Department of Internal Medicine and Therapeutics, University of Pavia, Piazzale Golgi 19, 27100 Pavia, Italy; First Department of Internal Medicine, IRCCS San Matteo Hospital Foundation, Piazzale Golgi 19, 27100 Pavia, Italy
| | - Giovanni Marasco
- Department of Medical and Surgical Sciences, University of Bologna, via Massarenti 9, 40138, Bologna, Italy; IRCCS Azienda Ospedaliero-Universitaria di Bologna, Via Albertoni 15, 40138, Bologna, Italy
| | - Mariabeatrice Principi
- Department of Precision and Regenerative Medicine and Ionian Area (DiMePRe-J), University of Bari, Piazza Umberto I, 70121, Bari, Italy
| | - Edoardo Vincenzo Savarino
- Gastroenterology Unit, Azienda Ospedale Università di Padova, via Nicolò Giustiniani 2, 35100, Padova, Italy; Department of Surgery, Oncology and Gastroenterology, University of Padua, via Nicolò Giustiniani 2, 35100, Italy
| | - Annalisa Tortora
- UOC Gastroenterologia, Azienda Ospedaliera Universitaria Integrata di Verona, Piazzale L.A. Scuro, 10, 37134 Verona VR, Italy
| | - Laura Obici
- Rare Diseases Unit and Amyloidosis Research and Treatment Centre, IRCCS San Matteo Hospital Foundation, viale Camillo Golgi 19, 27100, Pavia, Italy
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Jarava Delgado M, Gómez Torres KM, Gallardo Sánchez F. Beyond digestive pathology: endoscopic study in systemic disease. REVISTA ESPANOLA DE ENFERMEDADES DIGESTIVAS 2024. [PMID: 38469812 DOI: 10.17235/reed.2024.10324/2024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 03/13/2024]
Abstract
A 77-year-old male patient with heart disease, kidney disease under study, and quiescent multiple myeloma. He presented a 2 years history of weight loss and digestive symptoms. In the endoscopic study, multiple gastric ulcers were observed, whose histological study ruled out the initial suspicion. The patient died a month later from refractory shock.
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4
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Cheng N, Qin YJ, Zhang Q, Li H. ABCB4 gene mutation-associated cirrhosis with systemic amyloidosis: A case report. World J Clin Cases 2023; 11:4903-4911. [PMID: 37584002 PMCID: PMC10424036 DOI: 10.12998/wjcc.v11.i20.4903] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2023] [Revised: 04/22/2023] [Accepted: 06/13/2023] [Indexed: 07/11/2023] Open
Abstract
BACKGROUND Gene mutations in ATP-binding cassette, subfamily B (ABCB4) lead to autosomal recessive disorders. Primary light amyloidosis is a rare and incurable disease. Here, we report a rare case of liver cirrhosis caused by ABCB4 gene mutation combined with primary light amyloidosis. CASE SUMMARY We report a case of a 25-year-old female who was hospitalized due to recurrent abdominal pain caused by calculous cholecystitis and underwent cholecystectomy. Pathological examination of the liver tissue suggested liver cirrhosis with bile duct injury. Exon analyses of the whole genome from the patient's peripheral blood revealed the presence of a heterozygous mutation in the ABCB4 gene. Bone marrow biopsy tissues, renal puncture examination, and liver mass spectrometry confirmed the diagnosis of a rare progressive familial intrahepatic cholestasis type 3 with systemic light chain type κ amyloidosis, which resulted in cirrhosis. Ursodeoxycholic acid and the cluster of differentiation 38 monoclonal antibody daretozumab were administered for treatment. Following treatment, the patient demonstrated significant improvement. Urinary protein became negative, peripheral blood-free light chain and urine-free light chain levels returned to normal, and the electrocardiogram showed no abnormalities. Additionally, the patient's lower limb numbness resolved, and her condition remained stable. CONCLUSION This report presents the diagnosis and treatment of liver cirrhosis, a rare disease that is easily misdiagnosed or missed.
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Affiliation(s)
- Na Cheng
- Department of Infectious Diseases, Affiliated Hospital of Guizhou Medical University, Guizhou Medical University, Guiyang 550025, Guizhou Province, China
| | - Yu-Jie Qin
- Department of Infectious Diseases, Affiliated Hospital of Guizhou Medical University, Guizhou Medical University, Guiyang 550025, Guizhou Province, China
| | - Quan Zhang
- Department of Infectious Diseases, Affiliated Hospital of Guizhou Medical University, Guizhou Medical University, Guiyang 550025, Guizhou Province, China
| | - Hong Li
- Department of Infectious Diseases, Affiliated Hospital of Guizhou Medical University, Guizhou Medical University, Guiyang 550025, Guizhou Province, China
- Department of Infectious Diseases, Guizhou Provincial People's Hospital, Guiyang 550025, Guizhou Province, China
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5
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Cheng N, Qin YJ, Zhang Q, Li H. ABCB4 gene mutation-associated cirrhosis with systemic amyloidosis: A case report. World J Clin Cases 2023; 11:4899-4907. [DOI: 10.12998/wjcc.v11.i20.4899] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2023] [Revised: 04/22/2023] [Accepted: 06/13/2023] [Indexed: 07/06/2023] Open
Abstract
BACKGROUND Gene mutations in ATP-binding cassette, subfamily B (ABCB4) lead to autosomal recessive disorders. Primary light amyloidosis is a rare and incurable disease. Here, we report a rare case of liver cirrhosis caused by ABCB4 gene mutation combined with primary light amyloidosis.
CASE SUMMARY We report a case of a 25-year-old female who was hospitalized due to recurrent abdominal pain caused by calculous cholecystitis and underwent cholecystectomy. Pathological examination of the liver tissue suggested liver cirrhosis with bile duct injury. Exon analyses of the whole genome from the patient’s peripheral blood revealed the presence of a heterozygous mutation in the ABCB4 gene. Bone marrow biopsy tissues, renal puncture examination, and liver mass spectrometry confirmed the diagnosis of a rare progressive familial intrahepatic cholestasis type 3 with systemic light chain type κ amyloidosis, which resulted in cirrhosis. Ursodeoxycholic acid and the cluster of differentiation 38 monoclonal antibody daretozumab were administered for treatment. Following treatment, the patient demonstrated significant improvement. Urinary protein became negative, peripheral blood-free light chain and urine-free light chain levels returned to normal, and the electrocardiogram showed no abnormalities. Additionally, the patient’s lower limb numbness resolved, and her condition remained stable.
CONCLUSION This report presents the diagnosis and treatment of liver cirrhosis, a rare disease that is easily misdiagnosed or missed.
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Affiliation(s)
- Na Cheng
- Department of Infectious Diseases, Affiliated Hospital of Guizhou Medical University, Guizhou Medical University, Guiyang 550025, Guizhou Province, China
| | - Yu-Jie Qin
- Department of Infectious Diseases, Affiliated Hospital of Guizhou Medical University, Guizhou Medical University, Guiyang 550025, Guizhou Province, China
| | - Quan Zhang
- Department of Infectious Diseases, Affiliated Hospital of Guizhou Medical University, Guizhou Medical University, Guiyang 550025, Guizhou Province, China
| | - Hong Li
- Department of Infectious Diseases, Affiliated Hospital of Guizhou Medical University, Guizhou Medical University, Guiyang 550025, Guizhou Province, China
- Department of Infectious Diseases, Guizhou Provincial People's Hospital, Guiyang 550025, Guizhou Province, China
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Gomes ILC, Carlos ADS, Kum AST, Bestetti AM, de Moura EGH. Pseudotumoral Amyloidosis Presentation With Upper Digestive Bleeding. Cureus 2023; 15:e39094. [PMID: 37332419 PMCID: PMC10270430 DOI: 10.7759/cureus.39094] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/16/2023] [Indexed: 06/20/2023] Open
Abstract
Amyloidosis is a condition related to the extracellular deposition of abnormal fibrillar proteins. Gastric involvement may present as a systemic or localized form of the disease. The endoscopic presentation can vary from nodular, ulcerated, or infiltrative lesions. Clinical manifestations are nonspecific, including hyporexia, nausea, vomiting, weight loss, epigastralgia, and abdominal discomfort. Thus, amyloidosis can clinically and endoscopically mimic other diseases, such as neoplasms, syphilis, tuberculosis, and Crohn's disease, requiring a high suspicion. When it manifests with gastrointestinal bleeding, it most commonly occurs as intermittent melena. This report aims to present an unusual case of a patient with upper gastrointestinal bleeding exteriorized through melena secondary to amyloidosis with gastric involvement.
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Affiliation(s)
| | | | - Angelo So Taa Kum
- Gastroenterology, Faculdade de Medicina da Universidade de São Paulo, Sao Paulo, BRA
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Bou Zerdan M, Nasr L, Khalid F, Allam S, Bouferraa Y, Batool S, Tayyeb M, Adroja S, Mammadii M, Anwer F, Raza S, Chaulagain CP. Systemic AL amyloidosis: current approach and future direction. Oncotarget 2023; 14:384-394. [PMID: 37185672 PMCID: PMC10132994 DOI: 10.18632/oncotarget.28415] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/17/2023] Open
Abstract
Systemic Light chain (AL) amyloidosis is a monoclonal plasma cell proliferative disorder characterized by deposition of amyloidogenic monoclonal light chain fragments causing organ dysfunction. It is a fatal disease and if not diagnosed and treated early can lead to organ failure and potentially death. The renal system along with the cardiovascular system are the most common organs involved but other organs such as gut and liver can be involved as well. The initial evaluation of patients requires confirming the diagnosis with tissue biopsy and staining with Congo red followed by confirmatory typing with mass spectrometry of the Congo red positive tissue. Then establishing the extent of the organs involvement by various staging and biomarkers testing. The treatment options and the tolerability of therapy depend on the disease staging, frailty, and co-morbidities. The autologous hematopoietic cell transplantation (HCT) after high dose melphalan therapy is an effective strategy which is usually done after initial bortezomib induction therapy. Unfortunately, most systemic AL amyloidosis patients are not candidate for HCT due to frailty, old age, multi-organ involvement, renal and heart failure at the time of diagnosis. While it is widely accepted that the patients need to be treated until they achieve complete hematologic response, the maintenance therapy after HCT is not well established in AL amyloidosis. In this review, we report the literature on the latest treatment updates of AL amyloidosis and the ongoing clinical trials highlighting the future treatments.
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Affiliation(s)
- Maroun Bou Zerdan
- Department of Internal Medicine, SUNY Upstate Medical University, Syracuse, NY 13210, USA
| | - Lewis Nasr
- University of Texas MD Anderson Cancer Center, Houston, TX 77030, USA
| | - Farhan Khalid
- Department of Internal Medicine, Monmouth Medical Center, Long Branch, NJ 07740, USA
| | - Sabine Allam
- Department of Medicine and Medical Sciences, University of Balamand, Balamand, Lebanon
| | - Youssef Bouferraa
- Department of Internal Medicine, Cleveland Clinic, Cleveland, OH 44195, USA
| | - Saba Batool
- Department of Internal Medicine, UnityPoint Methodist, Peoria, IL 61636, USA
| | - Muhammad Tayyeb
- Department of Internal Medicine, Monmouth Medical Center, Long Branch, NJ 07740, USA
| | - Shubham Adroja
- Hematology and Medical Oncology, Houston Methodist Cancer Center, Houston, TX 77094, USA
| | - Mahinbanu Mammadii
- Department of Internal Medicine, SUNY Upstate Medical University, Syracuse, NY 13210, USA
| | - Faiz Anwer
- Department of Hematology-Oncology, Cleveland Clinic, Cleveland, OH 44195, USA
| | - Shahzad Raza
- Department of Hematology-Oncology, Cleveland Clinic, Cleveland, OH 44195, USA
| | - Chakra P Chaulagain
- Department of Hematology-Oncology, Myeloma and Amyloidosis Program, Maroone Cancer Center, Cleveland Clinic Florida, Weston, FL 33331, USA
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8
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Gubergrits NB, Mozhyna TL, Tsys OV, Rakhmetova VS. GASTRIC AND DUODENAL AMYLOIDOSIS IN AN HIV-INFECTED PATIENT: A CASE REPORT AND A LITERATURE REVIEW. WIADOMOSCI LEKARSKIE (WARSAW, POLAND : 1960) 2023; 76:1121-1129. [PMID: 37326098 DOI: 10.36740/wlek202305109] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/17/2023]
Abstract
We report the case of a 38-year-old female with gastrointestinal amyloidosis who presented with acute abdominal pain. The computed tomography scan showed that the patient had generalized lymphadenopathy. This clinical picture with absolute leukocytosis was interpreted as an acute secondary bacterial process of unspecified etiology with generalized lymphadenopathy. The patient was administered a broad-spectrum antibacterial drug and detoxication therapy. The upper endoscopy revealed bleeding of unknown origin. After a 2-day conservative hemostatic therapy, gastric tumor involvement was suggested during control endoscopy. The human immunodeficiency virus (HIV) antibodies were found with the following confirmation of their specificity by immunoblotting. Histopathological study of the biopsy specimens made it possible to diagnose gastrointestinal AA/AL-amyloidosis complicated by gastrointestinal bleeding.
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Affiliation(s)
| | | | - Oleksii V Tsys
- STATE SCIENTIFIC INSTITUTION «CENTER FOR INNOVATIVE MEDICAL TECHNOLOGIES OF THE NATIONAL ACADEMY OF SCIENCES OF UKRAINE», KYIV, UKRAINE
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9
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Staller KD, Badran YR, Rosman DA, Klempner SJ, Judelson R. Case 31-2022: A 72-Year-Old Man with Heartburn, Nausea, and Inability to Eat. N Engl J Med 2022; 387:1415-1424. [PMID: 36239648 DOI: 10.1056/nejmcpc2201239] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Affiliation(s)
- Kyle D Staller
- From the Departments of Medicine (K.D.S., Y.R.B., S.J.K.), Radiology (D.A.R.), and Pathology (R.J.), Massachusetts General Hospital, and the Departments of Medicine (K.D.S., Y.R.B., S.J.K.), Radiology (D.A.R.), and Pathology (R.J.), Harvard Medical School - both in Boston
| | - Yousef R Badran
- From the Departments of Medicine (K.D.S., Y.R.B., S.J.K.), Radiology (D.A.R.), and Pathology (R.J.), Massachusetts General Hospital, and the Departments of Medicine (K.D.S., Y.R.B., S.J.K.), Radiology (D.A.R.), and Pathology (R.J.), Harvard Medical School - both in Boston
| | - David A Rosman
- From the Departments of Medicine (K.D.S., Y.R.B., S.J.K.), Radiology (D.A.R.), and Pathology (R.J.), Massachusetts General Hospital, and the Departments of Medicine (K.D.S., Y.R.B., S.J.K.), Radiology (D.A.R.), and Pathology (R.J.), Harvard Medical School - both in Boston
| | - Samuel J Klempner
- From the Departments of Medicine (K.D.S., Y.R.B., S.J.K.), Radiology (D.A.R.), and Pathology (R.J.), Massachusetts General Hospital, and the Departments of Medicine (K.D.S., Y.R.B., S.J.K.), Radiology (D.A.R.), and Pathology (R.J.), Harvard Medical School - both in Boston
| | - Richard Judelson
- From the Departments of Medicine (K.D.S., Y.R.B., S.J.K.), Radiology (D.A.R.), and Pathology (R.J.), Massachusetts General Hospital, and the Departments of Medicine (K.D.S., Y.R.B., S.J.K.), Radiology (D.A.R.), and Pathology (R.J.), Harvard Medical School - both in Boston
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Oh GM, Park SJ, Kim JH, Jung K, Kim SE, Moon W, Park MI, Chang HK. Localized gastric amyloidosis successfully treated with endoscopic submucosal dissection: A case report. Medicine (Baltimore) 2021; 100:e28422. [PMID: 34941190 PMCID: PMC8702132 DOI: 10.1097/md.0000000000028422] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/11/2021] [Accepted: 12/06/2021] [Indexed: 11/30/2022] Open
Abstract
RATIONALE Amyloidosis is a general term that refers to the extracellular deposition of amyloid. The amyloid can also be deposited in a single organ. However, cases of localized gastric amyloidosis have rarely been reported. Here, we report a case of localized gastric amyloidosis that was successfully treated with endoscopic submucosal dissection. PATIENT CONCERN A 60-years-old man underwent esophagogastroduodenoscopy as part of a regular check-up without any comorbidities or symptoms. DIAGNOSTICS A 12 mm-sized, round, elevated lesion with a central depression, which was covered with normal mucosa, and located on the greater curvature of the lower body of the stomach was discovered during endoscopy. Subsequently, endoscopic ultrasonography was performed, which revealed a 11.7 mm-sized, hypoechoic, heterogeneous lesion located in the muscularis mucosa and submucosa. A biopsy was performed, and amyloid deposition was confirmed. Although other investigations for checking systemic amyloidosis were performed, there were no specific findings. Therefore, the final diagnosis was localized gastric amyloidosis. INTERVENTIONS Endoscopic submucosal dissection was performed according to the patient's request and the lesion was completely removed. OUTCOMES The patient was followed-up for 3 years without any recurrence. CONCLUSIONS Endoscopic submucosal dissection can be good diagnostic and treatment option for localized gastric amyloidosis.
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Affiliation(s)
- Gyu Man Oh
- Department of Internal Medicine, Kosin University College of Medicine, Busan, Korea
| | - Seun Ja Park
- Department of Internal Medicine, Kosin University College of Medicine, Busan, Korea
| | - Jae Hyun Kim
- Department of Internal Medicine, Kosin University College of Medicine, Busan, Korea
| | - Kyoungwon Jung
- Department of Internal Medicine, Kosin University College of Medicine, Busan, Korea
| | - Sung Eun Kim
- Department of Internal Medicine, Kosin University College of Medicine, Busan, Korea
| | - Won Moon
- Department of Internal Medicine, Kosin University College of Medicine, Busan, Korea
| | - Moo In Park
- Department of Internal Medicine, Kosin University College of Medicine, Busan, Korea
| | - Hee-Kyung Chang
- Department of Pathology, Kosin University College of Medicine, Busan, Korea
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