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症例は44歳の男性で,アメーバ性大腸炎,肝膿瘍の既往あり.左下腹部痛,血便が出現したが放置.2か月後,腹痛が増悪し,近医を受診した.画像検査所見上,腹腔内遊離ガス像,下部内視鏡検査にてS状結腸までにタコイボ状の多発性潰瘍を認めた.Human Immunodeficiency Virus(以下,HIV)抗体陽性であり,当院に転院した.アメーバ性大腸炎穿孔による腹膜炎と診断し,緊急手術を施行した.S状結腸に穿孔を認め,Hartmann手術を施行した.術後の検査でアメーバ原虫が認められ,メトロニダゾールの内服を開始した.2週間後に人工肛門が脱落し,再手術を施行した.全大腸が浮腫状かつ脆弱で,全層性の腸管壊死が疑われ,大腸亜全摘,回腸瘻造設術を施行することで救命しえた.劇症型アメーバ性大腸炎の死亡率は極めて高い.早期診断.抗アメーバ剤投与,症例に適した術式を選択することが救命へとつながる.
We reported a case of fulminant amoebic colitis with HIV infection. A 44-year-old man with a history of amoebic colitis and liver abscess admitted for left lower abdominal pain and bloody diarrhea. Free air was detected in the abdominal cavity by CT examination. Colonoscopy showed multiple ulcers in the sigmoid colon and rectum. The patient also had a history of HIV infection, and CD4 on admission was markedly decreased. He underwent emergency laparotomy with Hartmann's procedure due to peritonitis with perforated colitis. We confirmed the presence of Entamoeba histolytica trophozoides by histopathological examination. Despite metoronidazole administration, the colostomy became necrotic, with necrotic tissue observed in the ascending colon two weeks after the first operation. We conducted subtotal colectomy and ileostomy due to gangrenous change in all layers of the residual colon observed after laparotomy. The postoperative course was good and he was discharged four months after the second operation. This case suggests that staged surgery with Hartmann's procedure and subtotal colectomy may be useful in treating emergency cases of fulminant amoebic colitis.
