M. avium complex の肺感染に難治性の気胸を併発し, 左肺全摘で判明した左肺形成不全の1成人例 AN ADULT CASE OF HYPOPLASIA OF THE LEFT LUNG DISCLOSED BY PNEUMONECTOMY FOR PULMONARY M. AVIUM COMPLEX INFECTION ASSOCIATED WITH INTRACTABLE PNEUMOTHORAX
患者は52歳男性, Wolff-Parkinson-White's syndrome (以下WPW症候群と略) を合併し, 短期間に肺病変が進行拡大して病期<I>l</I>II2で来院, 検痰の結果<I>Mycobact6rium intracellulare</I> (以下MACと略) と判明した。化学療法開始10カ月後より気胸を併発し, 難治で緊張性気胸に移行したため受診1年2カ月で左肺を全摘した。上葉は舌区の欠損, S3に鶏卵大の含気性の先天性肺嚢胞形成と, 残余の後肺尖区はMAC症による無気肺硬化を認めた。一方下葉は胸膜の短縮による変形, 下縁の鈍化挙上とS6のMAC症病変で, 左肺は一層含気の低下を招き合併した気胸は難治と判明した。術後PaO2が初診時の76.6torrより99.2torrに上昇し, 合併症もなく, 患者は早期に軽快退院した。本症例は肺の末梢気道と肺実質の形成不全であり, このような形成不全肺は感染を受けやすいといわれているが, 抗酸菌感染の報告は少ない。
A case of W-P-W syndrome complicated with pulmonary hypoplasia disclosed by pneumonectomy for pulmonary <I>Mycobacterium avium</I> complex infection associated with intractable pneumothorax was reported. A male patient aged 52 years consulted our clinic with chief complaints of cough and abnormal shadows on his chest radiogram, which was consistent with mycobacteriosis on his left lung. MAC infection was soon confirmed by sputum examination and he was treated with RFP, EB, INH combined with CAM. In spite of the chemotherapy, sputum examination of the patient remained positive. Furthermore, eleven months after initiating the treatment, an intractable pneumothorax concurrent with a large dead space at the left lower lung field was consistently observed on his chest radiogram. Therefore, he was first treated by video assisted thoracoscopic surgery, but soon relapsed which led to tention pneumothorax gradually. Consequently, a left pneumonectomy had to be performed and the following developmental abnormalities combined with pathological changes caused by MAC infection were disclosed: concerning the upper lobe, defect of lingula, formation of a peripheral type of congenital air-filled parenchymal cyst measuring 5 × 6 cm in S3, and atelectatic induration caused by MAC infection on the remaining part of the upper lobe where strong adhesion was seen between the chest wall and the lung. Concerning the lower lobe, congenital shortening of visceral pleura, mainly mediastinal surface, causing marked deformity of the lower lobe with elevation of margo inferior. This created a large dead space between the lower lobe and diaphragma, and formation of a walnut-sized nest of atelectatic induration caused by MAC infection in S<SUP>6</SUP>. The patient's post-operative clinical course was uneventful and his arterial blood gas was elevated from 76 torr to 99.2 ton. He was discharged three weeks after the operation.<BR>Several controversial issues relating to this case were discussed; the predisposition existing on the hypoplastic lung to MAC infection, the possible reason why the congenital pulmonary cyst was not involved in MAC infection, the location of perforation of the upper lobe that caused intractable pneumothorax, and the difficulty in diagnosing congenital air-filled bullous parenchymal cyst by current conventional chest radiogram.
結核 78(11), 699-704, 2003-11-15
JAPANESE SOCIETY FOR TUBERCULOSIS