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一時心停止に陥った溶血性連鎖球菌による原発性腹膜炎の1例(Primary peritonitis due to Streptococcus pyogenes leading to temporary cardiac arrest: a case report)

要旨 症例は56歳の女性で,ショック状態のため,他院から紹介となる。初期輸液やカテコラミンに反応せず,一時心肺停止になった。蘇生後もショック状態を認め,Direct hemoperfusion with polymyxin B immobilized fiberを導入した。CT検査上,腹水と腸管壁の肥厚を認めたため,診断的腹腔洗浄を行った。白色に混濁した腹水を認め,緊急手術を施行した。膿性混濁腹水と子宮に膿苔を認めたが,腸管穿孔は認めなかったため,腹腔内を洗浄後,持続灌流洗浄を開始し集中治療を継続した。血液,腹水培養検査上,Streptococcus pyogenesを検出し,Streptoc...

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Published in:Nihon Kyūkyū Igakkai zasshi 2016-11, Vol.27 (11), p.735-740
Main Authors: (Futoshi Nagashima), 永嶋 太, (Satoshi Inoue), 井上 聡, (Yuuichirou Sakamoto), 阪本 雄一郎, (Kazuyuki Oka), 岡 和幸, (Yuki Bansyoutani), 番匠谷 友紀, (Daisaku Matsui), 松井 大作, (Makoto Kobayashi), 小林 誠人
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Language:English
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Summary:要旨 症例は56歳の女性で,ショック状態のため,他院から紹介となる。初期輸液やカテコラミンに反応せず,一時心肺停止になった。蘇生後もショック状態を認め,Direct hemoperfusion with polymyxin B immobilized fiberを導入した。CT検査上,腹水と腸管壁の肥厚を認めたため,診断的腹腔洗浄を行った。白色に混濁した腹水を認め,緊急手術を施行した。膿性混濁腹水と子宮に膿苔を認めたが,腸管穿孔は認めなかったため,腹腔内を洗浄後,持続灌流洗浄を開始し集中治療を継続した。血液,腹水培養検査上,Streptococcus pyogenesを検出し,Streptococcal Toxic Shock Syndrome(STSS)の診断基準を満たした。その後,徐々に状態は安定し,16病日に一般病棟に転棟した。本症例はAcute Physiology and Chronic Health Evaluation II score 49点,Sequential Organ Failure Assessment score 18点であった。Streptococcus pyogenesによる原発性腹膜炎は稀な疾患であるが,STSSを発症すると急激に悪化し心停止にもなる重篤な疾患である。救命のためには,早期診断,迅速な外科的治療および適切な集中治療が必要であると考えられた。 ABSTRACT A 56–year–old woman was admitted to our hospital with hemodynamic collapse. The patient fell into a temporal cardiac arrest despite initial resuscitation. Since her circulation remained unstable after a successful cardiopulmonary resuscitation, Direct hemoperfusion with polymyxin B immobilized fiber was performed. The diagnostic peritoneal lavage (DPL) was performed as CT scan showed peritoneal fluid and wall thickening of the small intestine. We opted for an immediate surgery as the DPL showed cloudy fluid. A swollen uterus with purulent and mossy ascites but no bowel perforations were observed at laparotomy. The intraperitoneal space was irrigated and intensive care was continued with continuous intraperitoneal irrigation. The blood and ascites cultures were positive for Streptococcus pyogenes and Streptococcal Toxic Shock Syndrome (STSS) was diagnosed based on its diagnostic criteria. Her general conditions improved and she moved to the general ward on the 16th hospital day. Acute Physiology and Chronic Health Evaluation II score and Sequential Organ Failure Assessment score was 49 and 18 respectively. Primary peritonitis due to Streptococcus pyogenes is rare. Once STSS occurs, it deteriorates the patient’s condition rapidly and can result in death. Therefore, it is imperative to promptly diagnose to perform Emergency surgery followed by intensive care.
ISSN:1883-3772
1883-3772
DOI:10.1002/jja2.12122