直腸穿孔を来した劇症型溶連菌感染症の1例(A case of group A invasive streptococcal shock syndrome with rectal perforation)

• Published in: Nihon Kyūkyū Igakkai zasshi 2018-07, Vol.29 (7), p.202-207
• Main Authors: (Makoto Aoki), 青木 誠, (Yusuke Sawada), 澤田 悠輔, (Shuichi Hagiwara), 萩原 周一, (Masato Murata), 村田 将人, (Kiyohiro Oshima), 大嶋 清宏
• Format: Article
• Language: English
• Subjects: acute abdomen; sepsis; surgical drainage; 外科ドレナージ; 急性腹症; 敗血症
• ISSN: 1883-3772; 1883-3772
• DOI: 10.1002/jja2.12299

要旨 　症例は44歳の男性。発熱と腹痛のため前医受診し腸炎の診断で入院となったが，状態悪化したため翌日当科へ転院した。当院搬送時，下腹部に軽度の自発痛を認めるものの明らかな圧痛，腹膜刺激徴候などはなかった。当院での入院加療開始約6時間後痙攣発作，さらには心肺停止状態に陥り蘇生処置を行った。入院第4病日に前医で採取された血液培養検査でStreptococcus pyogenes Aが検出されるとともに，入院第5病日の髄液検査でも溶連菌が検出され，劇症型溶連菌感染症による直腸炎，二次性腹膜炎，髄膜炎と診断した。直腸炎，二次性腹膜炎の治療については当初より抗菌化学療法とともにドレナージ治療を並行して行ったが，病勢制御に難渋し最終的に直腸穿孔を来した。劇症型溶連菌感染症には急性腹症で発症する病態が存在する。劇症型溶連菌感染症による腹部病変の制御には全身状態を加味した早期外科的介入が重要であると考えられた。 ABSTRACT A 44–year–old man went to a local hospital due to fever and abdominal pain, and he was diagnosed with colitis and was hospitalized. On the next day, his condition worsened and he was transferred to our hospital. On arrival at our hospital, he had slight pain in the lower abdomen and no peritoneal irritation sign. Six hours after arrival, he had a convulsive seizure and suffered cardiopulmonary arrest; however, soon after resuscitation, he had return of spontaneous circulation. On admission day 4, the blood culture at the previous hospital revealed group A Streptococcus pyogenes, and on admission day 5, group A Streptococcus pyogenes was also found in his cerebrospinal fluid. He was diagnosed with group A invasive streptococcal shock syndrome with proctitis, secondary peritonitis and meningitis. The proctitis and secondary peritonitis were treated with antibiotic chemical treatment and drainage; however, we had difficulty in controlling the abdominal state and the patient eventually suffered rectal perforation. Rectal perforation was conservatively treated. In group A invasive streptococcal shock syndrome, acute abdomen can present. It is assumed that early surgical procedure can control abdominal disease lesions.