髄液のQuantiFERON® TB-2G検査により，結核性髄膜炎を早期に診断できた一例
症例は，結核症の既往のない53歳男性。意識障害で救急搬送され，発熱と項部硬直より髄膜炎を疑われ，入院となった。髄液はリンパ球優位の細胞数393μl−1と増加を認め，非細菌性髄膜炎と考えられた。髄液塗抹陰性，結核菌single step polymerase chain reaction（PCR）陰性であり，確定診断がつかないまま，徐々に意識障害の進行を認め，第9病日に気道管理が必要となり，ICUへ入室した。髄液所見，脳底槽に強いくも膜炎，両側大脳基底核の脳梗塞など，臨床的に結核性髄膜炎が強く疑われたため，第10病日より抗結核薬及びステロイド投与を開始した。一方で診断のため，末梢血のQuanti...
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| Published in | 日本集中治療医学会雑誌 Vol. 17; no. 3; pp. 303 - 308 |
|---|---|
| Main Authors | , , , , , , , |
| Format | Journal Article |
| Language | Japanese |
| Published |
一般社団法人 日本集中治療医学会
2010
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| Online Access | Get full text |
| ISSN | 1340-7988 1882-966X |
| DOI | 10.3918/jsicm.17.303 |
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| Abstract | 症例は，結核症の既往のない53歳男性。意識障害で救急搬送され，発熱と項部硬直より髄膜炎を疑われ，入院となった。髄液はリンパ球優位の細胞数393μl−1と増加を認め，非細菌性髄膜炎と考えられた。髄液塗抹陰性，結核菌single step polymerase chain reaction（PCR）陰性であり，確定診断がつかないまま，徐々に意識障害の進行を認め，第9病日に気道管理が必要となり，ICUへ入室した。髄液所見，脳底槽に強いくも膜炎，両側大脳基底核の脳梗塞など，臨床的に結核性髄膜炎が強く疑われたため，第10病日より抗結核薬及びステロイド投与を開始した。一方で診断のため，末梢血のQuantiFERON® TB-2G（以下QFT-2G），髄液のQFT-2G，髄液のnested PCR検査を依頼した。第15病日に髄液のQFT-2Gが陽性となり，第51病日にMycobacterium tuberculosisが培養され，確定診断に至った。髄液のQFT-2G検査は，結核性髄膜炎の早期診断に有用と思われる。 |
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| AbstractList | 症例は，結核症の既往のない53歳男性。意識障害で救急搬送され，発熱と項部硬直より髄膜炎を疑われ，入院となった。髄液はリンパ球優位の細胞数393μl−1と増加を認め，非細菌性髄膜炎と考えられた。髄液塗抹陰性，結核菌single step polymerase chain reaction（PCR）陰性であり，確定診断がつかないまま，徐々に意識障害の進行を認め，第9病日に気道管理が必要となり，ICUへ入室した。髄液所見，脳底槽に強いくも膜炎，両側大脳基底核の脳梗塞など，臨床的に結核性髄膜炎が強く疑われたため，第10病日より抗結核薬及びステロイド投与を開始した。一方で診断のため，末梢血のQuantiFERON® TB-2G（以下QFT-2G），髄液のQFT-2G，髄液のnested PCR検査を依頼した。第15病日に髄液のQFT-2Gが陽性となり，第51病日にMycobacterium tuberculosisが培養され，確定診断に至った。髄液のQFT-2G検査は，結核性髄膜炎の早期診断に有用と思われる。 |
| Author | 岡田, 保誠 小島, 直樹 西村, 祥一 佐々木, 庸郎 山口, 和将 稲川, 博司 古谷, 良輔 津嘉山, 博行 |
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| References | 7) Pai M, Zwerling A, Menzies D. Systematic review: T-cell-based assays for the diagnosis of latent tuberculosis infection: an update. Ann Intern Med 2008;149:177-84. 13) 正本庸介, 古川恵一. 結核性髄膜炎の診断のための指標 —振戦を伴う亜急性髄膜炎は結核性髄膜炎を疑う—. 感染症誌 2007;81:765-6. 11) Thwaites GE, Chau TTH, Stepniewska K, et al. Diagnosis of adult tuberculous meningitis by use of clinical and laboratory features. Lancet 2002;360:1287-92. 17) Chan KH, Cheung RTF, Fong CY, et al. Clinical relevance of hydrocephpalus as a presenting feature of tuberculous meningitis. QJM 2003;96:643-8. 4) Thwaites GE, Chau TTH, Farrar JJ. Improving the bacteriological diagnosis of tuberculous meningitis. J Clin Microbiol 2004;42:378-9. 6) Takahashi T, Nakayama T, Tamura M, et al. Nested polymerase chain reaction for assessing the clinical course of tuberculous meningitis. Neurology 2005;64:1789-93. 16) Özates M, Kemaloglu S, Gürkan F, et al. CT of the brain in tuberculous meningitis. A review of 289 patients. Acta Radiol 2000;41:13-7. 8) Simmons CP, Thwaites GE, Quyen NT, et al. Pretreatment intracerebral and peripheral blood immune responses in Vietnamese adults with tuberculous meningitis: diagnostic value and relationship to disease severity and outcome. J Immunol 2006;176:2007-14. 15) Brouwer MC, van de Beek D, Heckenberg SG, et al. Hyponatremia in adults with community-acquired bacterial meningitis. QJM 2007;100:37-40. 3) Thomas MM, Hinks TSC, Raghuraman S, et al. Rapid diagnosis of Mycobacterium tuberculosis meningitis by enumeration of cerebrospinal fluid antigen-specific T-cells. Int J Tuberc Lung Dis 2008;12:651-7. 14) Davis LE, Rastogi KR, Lambert LC, et al. Tuberculous meningitis in the southwest United States: a community-based study. Neurology 1993;43:1775-8. 10) Ariga H, Kawabe Y, Nagai H, et al. Diagnosis of active tuberculous serositis by antigen-specific interferon-gamma response of cavity fluid cells. Clin Infect Dis 2007;45:1559-67. 2) Kennedy DH, Fallon RJ. Tuberculous meningitis. JAMA 1979; 241:264-8. 5) Pai M, Flores LL, Pai N, et al. Diagnostic accuracy of nucleic acid amplification tests for tuberculous meningitis: a systematic review and meta-analysis. Lancet Infect Dis 2003;3:633-43. 1) Thwaites GE, Nguyen DB, Nguyen HD, et al. Dexamethasone for the treatment of tuberculous meningitis in adolescents and adults. N Engl J Med 2004;351:1741-51. 12) Alarcón F, Dueñas G, Cevallos N, et al. Movement disorders in 30 patients with tuberculous meningitis. Mov Disord 2000;15:561-9. 9) Wilkinson KA, Wilkinson RJ, Pathan A, et al. Ex vivo characterization of early secretory antigenic target 6 specific T cells at sites of active disease in pleural tuberculosis. Clin Infect Dis 2005;40:184-7. |
| References_xml | – reference: 9) Wilkinson KA, Wilkinson RJ, Pathan A, et al. Ex vivo characterization of early secretory antigenic target 6 specific T cells at sites of active disease in pleural tuberculosis. Clin Infect Dis 2005;40:184-7. – reference: 10) Ariga H, Kawabe Y, Nagai H, et al. Diagnosis of active tuberculous serositis by antigen-specific interferon-gamma response of cavity fluid cells. Clin Infect Dis 2007;45:1559-67. – reference: 13) 正本庸介, 古川恵一. 結核性髄膜炎の診断のための指標 —振戦を伴う亜急性髄膜炎は結核性髄膜炎を疑う—. 感染症誌 2007;81:765-6. – reference: 14) Davis LE, Rastogi KR, Lambert LC, et al. Tuberculous meningitis in the southwest United States: a community-based study. Neurology 1993;43:1775-8. – reference: 5) Pai M, Flores LL, Pai N, et al. Diagnostic accuracy of nucleic acid amplification tests for tuberculous meningitis: a systematic review and meta-analysis. Lancet Infect Dis 2003;3:633-43. – reference: 16) Özates M, Kemaloglu S, Gürkan F, et al. CT of the brain in tuberculous meningitis. A review of 289 patients. Acta Radiol 2000;41:13-7. – reference: 3) Thomas MM, Hinks TSC, Raghuraman S, et al. Rapid diagnosis of Mycobacterium tuberculosis meningitis by enumeration of cerebrospinal fluid antigen-specific T-cells. Int J Tuberc Lung Dis 2008;12:651-7. – reference: 7) Pai M, Zwerling A, Menzies D. Systematic review: T-cell-based assays for the diagnosis of latent tuberculosis infection: an update. Ann Intern Med 2008;149:177-84. – reference: 12) Alarcón F, Dueñas G, Cevallos N, et al. Movement disorders in 30 patients with tuberculous meningitis. Mov Disord 2000;15:561-9. – reference: 15) Brouwer MC, van de Beek D, Heckenberg SG, et al. Hyponatremia in adults with community-acquired bacterial meningitis. QJM 2007;100:37-40. – reference: 1) Thwaites GE, Nguyen DB, Nguyen HD, et al. Dexamethasone for the treatment of tuberculous meningitis in adolescents and adults. N Engl J Med 2004;351:1741-51. – reference: 6) Takahashi T, Nakayama T, Tamura M, et al. Nested polymerase chain reaction for assessing the clinical course of tuberculous meningitis. Neurology 2005;64:1789-93. – reference: 2) Kennedy DH, Fallon RJ. Tuberculous meningitis. JAMA 1979; 241:264-8. – reference: 8) Simmons CP, Thwaites GE, Quyen NT, et al. Pretreatment intracerebral and peripheral blood immune responses in Vietnamese adults with tuberculous meningitis: diagnostic value and relationship to disease severity and outcome. J Immunol 2006;176:2007-14. – reference: 11) Thwaites GE, Chau TTH, Stepniewska K, et al. Diagnosis of adult tuberculous meningitis by use of clinical and laboratory features. Lancet 2002;360:1287-92. – reference: 4) Thwaites GE, Chau TTH, Farrar JJ. Improving the bacteriological diagnosis of tuberculous meningitis. J Clin Microbiol 2004;42:378-9. – reference: 17) Chan KH, Cheung RTF, Fong CY, et al. Clinical relevance of hydrocephpalus as a presenting feature of tuberculous meningitis. QJM 2003;96:643-8. |
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| Snippet | 症例は，結核症の既往のない53歳男性。意識障害で救急搬送され，発熱と項部硬直より髄膜炎を疑われ，入院となった。髄液はリンパ球優位の細胞数393μl−1と増加を認め，非細菌... |
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| Title | 髄液のQuantiFERON® TB-2G検査により，結核性髄膜炎を早期に診断できた一例 |
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