A 53-year-old man presented with unstable angina due to the severe stenosis of the left anterior descending coronary artery and obtuse marginalis, although the right coronary artery was normal. Laboratory findings, including a complete blood count, erythrocyte sedimentation rate, and C reactive protein, were normal. Chest X-ray revealed no abnormal findings, and there was no valvular abnormality on preoperative echocardiography. The patient had no co-morbid disorders, but his left ventricular ejection fraction was reduced (40–45%).\nThe intraoperative course was uneventful. There were no findings of pericarditis. On physical examination, there was no respiratory distress, blood pressure was 130/80 mm Hg, heart rate was 80 beats per minute, respiratory rate was 23 per minute, the neck veins were not distended, and there was no ankle edema. Cardiovascular system examination showed regular first and second heart sounds with no gallop or murmur. The electrocardiogram (ECG) demonstrated a Q wave in the precordial leads. For temporary coronary artery occlusion, 4/0 Viline sutures and a Bulldog Clamp were used, and warm blood was employed to de air the graft. Temporary coronary artery occlusion was not prolonged, and the electrocardiogram and hemodynamic variables and objective data showed no signs of ischemia or contractile dysfunction. The operation was uneventful. No intra-coronary shunt was utilized.\nThe patient left the operating room without any inotropic support. Six hours later, however, he developed low cardiac output. At exploration, cardiac tamponade was excluded and flowmetry showed that the graft had adequate function. There were no findings as regards pericarditis, and the patient’s postoperative erythrocyte sedimentation rate, C-reactive protein, and cardiac enzymes were normal. A high dose of adrenalin and dobutamine was administered, and an intra-aortic balloon pump was used.\nIntraoperative transesophageal echocardiography demonstrated a depression in the left ventricular function due to an akinetic lateral left ventricular wall in the region of the obtuse marginalis. After hemodynamic stabilization, the patient left the Intensive Care Unit without an intra-aortic balloon pump and inotropic support. On the fifth postoperative day, a coronary angiogram demonstrated patent grafts and correct anastomotic sites ( & ). On the seventh postoperative day, the akinetic lateral wall of the left ventricle changed to dyskinesia. Finally, after hospital discharge on the thirtieth postoperative day, an echocardiogram showed a normal left ventricular function without regional wall motion abnormalities.
In April 2013, a 42-year-old male was diagnosed with stage IIIB testicular cancer in accordance with the American Joint Committee on Cancer Staing Classification () at the Kangwon National University Hospital (Chuncheon, Korea). The histology revealed non-seminomatous germ cell tumor (NSGCT) comprising seminoma (60%), yolk sac tumor (25%), embryonal carcinoma (10%) and teratoma (5%). Following orchiectomy, serum α-fetoprotein (αFP) levels were 20 ng/ml and lactate dehydrogenase (LDH) levels were 298 U/l (normal, <190 U/l). Computed tomography (CT) scanning showed pre- and para-aortic lymphadenopathy ≤3.6 cm. There was no medical history of note and, specifically, no history of dermatological disorders or allergy. The pateint’s pulmonary function test results were normal. The patient was commenced on bleomycin, etoposide and cisplatin chemotherapy, intravenously from May 20, 2013 in the outpatient clinic. Bleomycin (30 units) was scheduled to be administered on days 2, 9 and 16, while etoposide (100 mg/m2) and cisplatin (20 mg/m2) were administered for 5 days from day 1. Treatment was intended to be repeated every three weeks. After 10 days from the start of treatment, the patient subsequently developed a generalized pruritus and erythematous linear rash that was most prominent on the trunk and upper and lower extremities. The patient visited the emergency room (ER) and was given antihistamine. The patient then revisited the clinic for bleomycin treatment on day 16, and the rash in which the patient appeared to have been whipped over multiple body areas was observed. Physical examination showed the appearance of an erythematous popular rash on the whole body, with evidence of dermatographia (). There were no scales or lichenification, and the patient’s vital signs were normal. Laboratory tests at ER showed a white blood cell count of 3,800/mm3 (normal range, 3,800–10,000/mm3) (segmented neutrophils, 70%; lymphocytes, 24%; and eosinophils, 3%), hemoglobin levels of 13.7 g/dl (normal range, 13.3–16.5 g/dl), a platelet count of 313,000/mm3 (normal range, 140,000–400,000/mm3), serum LDH levels of 208 U/l (normal range, <190 U/l) and C-reactive protein levels of 5.35 mg/dl (normal range, <0.75 mg/dl). Prothrombin time and activated prothrombin time were 11.5 (normal range, 12.1–14.5 sec) and 36.7 sec (normal range, 31.0–43.7 sec), respectively.\nA skin biopsy of a right forearm lesion was taken. Bleomycin treatment on day 16 was cancelled. Pathological examination of the skin biopsy showed endothelial swelling and perivascular mononuclear cell infiltration present in the superficial and deep dermis (). The findings were considered to be consistent with a systemic hypersensitivity reaction. Given the patient’s clinical history and the gross appearance of the lesions, the diagnosis was most compatible with a severe bleomycin-induced flagellate erythema reaction. The patient was commenced on a short course of oral prednisolone, 20 mg daily, and antihistamine. The itching sensation was improved, but mild hyperpigmentation remained.\nConsequently, bleomycin was withheld from the treatment regimen. As the patient’s NSGCT was intermediate-risk, we recommended that the regimen should be changed to etoposide, ifosfamide and cisplatin. However, the patient refused to add ifosfamide following a discussion of the possible toxicities. Tumor markers, such as αFP and LDH levels, were normalized within 3 weeks of the first cycle of chemotherapy. Following a further three cycles of etoposide 100( mg/m2, days 1–5) and cisplatin (20 mg/m2, days 1–5), without bleomycin, every three weeks, no remnant mass was visible in the abdomen on positron emission tomography-CT.