結核菌培養検査で陽性となるまでに時間を要した全身播種結核患者の1例 A CASE OF DISSEMINATED TUBERCULOSIS REQUIRING EXTENDED PERIOD FOR THE IDENTIFICATION OF MYCOBACTERIUM TUBERCULOSIS ON CULTURE
80歳, 男性・発熱, 咳, 食欲不振を主訴に2000年6月に近医を受診した. 患者は原因を特定できないまま細菌性肺炎と診断され抗菌薬による治療を受けた. 1カ月後, 改善を認めないため入院となった. 入院後, 気管支洗浄液から抗酸菌が検出され当科紹介入院となった. 入院時の喀疾塗抹検査にて抗酸菌が陽性でPCRにて結核菌と判明した. 抗結核剤の投与 (各々1日量;INH300mg, RFP450mg, EB1000mg, PZA1000mg) を開始した. しかし, 入院後, 患者の意識レベルの低下を認めた. 頭部MRIでは両側前頭-頭頂部の皮質内に多数の小結節影を認めた. 髄液中に抗酸菌は検出されなかったが, 結核性髄膜炎を疑い, ステロイドを投与された. 髄液所見およびMRI所見にて結核性髄膜炎と診断した. 入院後9日目に患者は結核性髄膜炎のため死亡した. 喀疾と髄液を小川の地にて培養したところ, いずれもコロニー形成まで14週間を要した. 死後の剖検では, 肺, 肝臓, 腎臓, 膵臓にびまん性に結核結節の形成を認めた. 試験管内において培養増殖速度が遅い結核菌によって発症した全身播種型結核症例を示した.
A 80-year-old male visited an outpatient department of a nearby hospital complaining of fever, cough, and poor appetite on June 2000. The patient was diagnosed as bacterial pneumonia and was treated with antibiotics although specific cause could not be identified. After one month, he was hospitalized due to lack of improvement. After admission, acid-fast bacilli (AFB) was found from the bronchial washing. The patient was then transferred to our hospital. Upon admission, sputum smear examination was positive for AFB and MTB was confirmed by PCR. Therapy was initiated with INH 300 mg, RFP 450 mg, EB 1000 mg, and PZA 1000 mg, orally daily. However, on the day following the admission, he became unconscious. Brain MRI showed several small granulomas on the cortex of the bilateral anterior and temporal brain. Although AFB was not detected from the c erebrospinal fluid, tuberculous meningitis was suspected and steroid was given. Nine days after admission, the patient died due to tuberculous meningitis. The isolation of MTB had been attempted on Ogawa culture medium using patient's sputum and liquor, and it took 14 weeks to find colony growth both from sputum and liquor. In the autopsy, numerous granulomas were detected in his lung, liver, kidney, and pancreas. These findings indicate that disseminated growth of MTB occurred in vivo in spite of very slow growth of MTB in vitro.
結核 77(2), 73-77, 2002-02-15
JAPANESE SOCIETY FOR TUBERCULOSIS