アルコール多飲者に発症した劇症型肺炎球菌感染症の1例
症例はアルコール多飲の生活歴をもつ生来健康な48歳の男性。発熱と全身の疼痛を主訴に近医を受診し，低体温と代謝性アシドーシスを認め，当院へ緊急搬送された。意識障害，低血圧，頻呼吸を呈し，四肢および体幹前面に紫斑を認めた。血液検査では肝・腎機能障害，凝固能異常，乳酸アシドーシスの所見があり，腹部CTで脾臓低形成を認めた。敗血症性ショックと播種性血管内凝固症候群（disseminated intravascular coagulation: DIC）と診断した。直ちに抗菌薬投与，人工呼吸器管理，持続的血液濾過透析，輸血などの集学的治療を行ったが，多臓器不全のため来院13時間後に死亡した。剖検の結果，...
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| Published in | 日本救急医学会雑誌 Vol. 25; no. 6; pp. 273 - 278 |
|---|---|
| Main Authors | , , |
| Format | Journal Article |
| Language | Japanese |
| Published |
一般社団法人 日本救急医学会
2014
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| Subjects | |
| Online Access | Get full text |
| ISSN | 0915-924X 1883-3772 |
| DOI | 10.3893/jjaam.25.273 |
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| Abstract | 症例はアルコール多飲の生活歴をもつ生来健康な48歳の男性。発熱と全身の疼痛を主訴に近医を受診し，低体温と代謝性アシドーシスを認め，当院へ緊急搬送された。意識障害，低血圧，頻呼吸を呈し，四肢および体幹前面に紫斑を認めた。血液検査では肝・腎機能障害，凝固能異常，乳酸アシドーシスの所見があり，腹部CTで脾臓低形成を認めた。敗血症性ショックと播種性血管内凝固症候群（disseminated intravascular coagulation: DIC）と診断した。直ちに抗菌薬投与，人工呼吸器管理，持続的血液濾過透析，輸血などの集学的治療を行ったが，多臓器不全のため来院13時間後に死亡した。剖検の結果，諸臓器の点状出血と微小血栓，副腎皮質出血，肺うっ血，脾臓低形成を認め，病理学的にはWaterhouse-Friedrichsen症候群，DIC，循環不全と診断された。局所の感染巣は不明であった。その後，入院時血液培養検査から肺炎球菌が検出され，劇症型肺炎球菌感染症と診断した。本邦において劇症型肺炎球菌感染症の剖検例の報告は少ない。劇症型肺炎球菌感染症は，極めて急速に敗血症，DIC，多臓器不全が進行する死亡率の高い疾患であり，今後剖検例を含めた症例報告を集積し，アルコール多飲など劇症化の因子を解明することが重要と考えられる。 |
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| AbstractList | 症例はアルコール多飲の生活歴をもつ生来健康な48歳の男性。発熱と全身の疼痛を主訴に近医を受診し，低体温と代謝性アシドーシスを認め，当院へ緊急搬送された。意識障害，低血圧，頻呼吸を呈し，四肢および体幹前面に紫斑を認めた。血液検査では肝・腎機能障害，凝固能異常，乳酸アシドーシスの所見があり，腹部CTで脾臓低形成を認めた。敗血症性ショックと播種性血管内凝固症候群（disseminated intravascular coagulation: DIC）と診断した。直ちに抗菌薬投与，人工呼吸器管理，持続的血液濾過透析，輸血などの集学的治療を行ったが，多臓器不全のため来院13時間後に死亡した。剖検の結果，諸臓器の点状出血と微小血栓，副腎皮質出血，肺うっ血，脾臓低形成を認め，病理学的にはWaterhouse-Friedrichsen症候群，DIC，循環不全と診断された。局所の感染巣は不明であった。その後，入院時血液培養検査から肺炎球菌が検出され，劇症型肺炎球菌感染症と診断した。本邦において劇症型肺炎球菌感染症の剖検例の報告は少ない。劇症型肺炎球菌感染症は，極めて急速に敗血症，DIC，多臓器不全が進行する死亡率の高い疾患であり，今後剖検例を含めた症例報告を集積し，アルコール多飲など劇症化の因子を解明することが重要と考えられる。 |
| Author | 西岡, 弘晶 亀井, 博紀 今井, 幸弘 |
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| References | 7) Paton JC, Ferrante A: Inhibition of human polymorphonuclear leukocyte respiratory burst, bactericidal activity, and migration by pneumolysin. Infect Immun. 1983; 41: 1212-6. 13) 久保健児, 千代孝夫, 岡本洋史, 他: 電撃性紫斑病の臨床的検討: 本邦における原因菌の特徴を含めて. 感染症誌. 2009; 83: 639-46. 6) Torres J, Bisno AL: Hyposplenism and pneumococcemia. Visualization of Diplococcus pneumoniae in the peripheral blood smear. Am J Med. 1973; 55: 851-5. 9) Paton JC, Andrew PW, Boulnois GJ, et al: Molecular analysis of the pathogenicity of Streptococcus pneumoniae: the role of pneumococcal proteins. Annu Rev Microbiol. 1993; 47: 89-115. 8) Ferrante A, Rowan-Kelly B, Paton JC: Inhibition of in vitro human lymphocyte response by the pneumococcal toxin pneumolysin. Infect Immun. 1984; 46: 585-9. 3) Urata Y, Hasegawa M, Hasegawa H, et al: A fatal case of overwhelming postsplenectomy infection syndrome developing 10 years after splenectomy. Jpn J Clin Immun. 1997; 20: 184-90. 5) Coonrod JD, Leach RP: Antigenemia in fulminant pneumococcemia. Ann Intern Med. 1976; 84: 561-3. 16) Vander Top EA, Wyatt TA, Gentry-Nielsen MJ: Smoke exposure exacerbates an ethanol-induced defect in mucociliary clearance of Streptococcus pneumoniae. Alcohol Clin Exp Res. 2005; 29: 882-7. 19) Roselle GA, Mendenhall CL, Grossman CJ, et al: Lymphocyte subset alterations in patients with alcoholic hepatitis. J Clin Lab Immunol. 1988; 26: 169-73. 14) Harboe ZB, Thomsen RW, Riis A, et al: Pneumococcal serotypes and mortality following invasive pneumococcal disease: a population-based cohort study. PLoS Med. 2009; 6: e1000081. doi:10.1371/journal.pmed.1000081. 11) Deodhar M, Kakkar N: An audit of splenectomies in a teaching hospital in North India. Are postsplenectomy guidelines being complied with? J Clin Pathol. 2004; 57: 407-10. 15) de Roux A, Cavalcanti M, Marcos MA, et al: Impact of alcohol abuse in the etiology and severity of community-acquired pneumonia. Chest. 2006; 129: 1219-25. 1) Taylor SN, Sanders CV: Unusual manifestations of invasive pneumococcal infection. Am J Med. 1999; 107: 12S-27S. 17) Mason CM, Dobard E, Kolls JK, et al: Ethanol and murine interleukin (IL)-12 production. Alcohol Clin Exp Res. 2000; 24: 553-9. 2) Working Party of the British Committee for Standards in Haematology Clinical Haematology Task Force: Guidelines for the prevention and treatment of infection in patients with an absent or dysfunctional spleen. BMJ. 1996; 312: 430-4. 4) Tajiri T, Tate G, Enosawa T, et al: Clinicopathological findings in fulminant-type pneumococcal infection: report of three autopsy cases. Pathol Int. 2007; 57: 606-12. 10) Cullingford GL, Watkins DN, Watts AD, et al: Severe late postsplenectomy infection. Br J Surg. 1991; 78: 716-21. 12) 神尾学, 日比野壮功, 松森響子, 他: 電撃性紫斑病, Waterhouse-Friderichsen症候群を呈した肺炎球菌感染症の1例. 日内会誌. 2012; 101: 1382-5. 18) Jareo PW, Preheim LC, Gentry MJ: Ethanol ingestion impairs neutrophil bactericidal mechanisms against Streptococcus pneumoniae. Alcohol Clin Exp Res. 1996; 20: 1646-52. |
| References_xml | – reference: 1) Taylor SN, Sanders CV: Unusual manifestations of invasive pneumococcal infection. Am J Med. 1999; 107: 12S-27S. – reference: 3) Urata Y, Hasegawa M, Hasegawa H, et al: A fatal case of overwhelming postsplenectomy infection syndrome developing 10 years after splenectomy. Jpn J Clin Immun. 1997; 20: 184-90. – reference: 5) Coonrod JD, Leach RP: Antigenemia in fulminant pneumococcemia. Ann Intern Med. 1976; 84: 561-3. – reference: 12) 神尾学, 日比野壮功, 松森響子, 他: 電撃性紫斑病, Waterhouse-Friderichsen症候群を呈した肺炎球菌感染症の1例. 日内会誌. 2012; 101: 1382-5. – reference: 9) Paton JC, Andrew PW, Boulnois GJ, et al: Molecular analysis of the pathogenicity of Streptococcus pneumoniae: the role of pneumococcal proteins. Annu Rev Microbiol. 1993; 47: 89-115. – reference: 15) de Roux A, Cavalcanti M, Marcos MA, et al: Impact of alcohol abuse in the etiology and severity of community-acquired pneumonia. Chest. 2006; 129: 1219-25. – reference: 10) Cullingford GL, Watkins DN, Watts AD, et al: Severe late postsplenectomy infection. Br J Surg. 1991; 78: 716-21. – reference: 8) Ferrante A, Rowan-Kelly B, Paton JC: Inhibition of in vitro human lymphocyte response by the pneumococcal toxin pneumolysin. Infect Immun. 1984; 46: 585-9. – reference: 4) Tajiri T, Tate G, Enosawa T, et al: Clinicopathological findings in fulminant-type pneumococcal infection: report of three autopsy cases. Pathol Int. 2007; 57: 606-12. – reference: 13) 久保健児, 千代孝夫, 岡本洋史, 他: 電撃性紫斑病の臨床的検討: 本邦における原因菌の特徴を含めて. 感染症誌. 2009; 83: 639-46. – reference: 19) Roselle GA, Mendenhall CL, Grossman CJ, et al: Lymphocyte subset alterations in patients with alcoholic hepatitis. J Clin Lab Immunol. 1988; 26: 169-73. – reference: 11) Deodhar M, Kakkar N: An audit of splenectomies in a teaching hospital in North India. Are postsplenectomy guidelines being complied with? J Clin Pathol. 2004; 57: 407-10. – reference: 7) Paton JC, Ferrante A: Inhibition of human polymorphonuclear leukocyte respiratory burst, bactericidal activity, and migration by pneumolysin. Infect Immun. 1983; 41: 1212-6. – reference: 14) Harboe ZB, Thomsen RW, Riis A, et al: Pneumococcal serotypes and mortality following invasive pneumococcal disease: a population-based cohort study. PLoS Med. 2009; 6: e1000081. doi:10.1371/journal.pmed.1000081. – reference: 2) Working Party of the British Committee for Standards in Haematology Clinical Haematology Task Force: Guidelines for the prevention and treatment of infection in patients with an absent or dysfunctional spleen. BMJ. 1996; 312: 430-4. – reference: 6) Torres J, Bisno AL: Hyposplenism and pneumococcemia. Visualization of Diplococcus pneumoniae in the peripheral blood smear. Am J Med. 1973; 55: 851-5. – reference: 16) Vander Top EA, Wyatt TA, Gentry-Nielsen MJ: Smoke exposure exacerbates an ethanol-induced defect in mucociliary clearance of Streptococcus pneumoniae. Alcohol Clin Exp Res. 2005; 29: 882-7. – reference: 17) Mason CM, Dobard E, Kolls JK, et al: Ethanol and murine interleukin (IL)-12 production. Alcohol Clin Exp Res. 2000; 24: 553-9. – reference: 18) Jareo PW, Preheim LC, Gentry MJ: Ethanol ingestion impairs neutrophil bactericidal mechanisms against Streptococcus pneumoniae. Alcohol Clin Exp Res. 1996; 20: 1646-52. |
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| Snippet | 症例はアルコール多飲の生活歴をもつ生来健康な48歳の男性。発熱と全身の疼痛を主訴に近医を受診し，低体温と代謝性アシドーシスを認め，当院へ緊急搬送された。意識障害，... |
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| SubjectTerms | Waterhouse-Friderichsen症候群 播種性血管内凝固症候群 脾臓低形成 |
| Title | アルコール多飲者に発症した劇症型肺炎球菌感染症の1例 |
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