Hisashi Funada

The air crescent sign of invasive pulmonary mucormycosis in acute leukemia

An unusual radiographic sign of crescentic cavitation appeared in a case of invasive pulmonary mucormycosis complicating the treatment of a patient with acute myelogenous leukemia and having a normal admission chest radiograph. The first manifestation was a large, wedge‐shaped pleural‐based consolidation, which evolved about 10 days later into a fungus ball‐like lesion, usually known as the air crescent sign. Amphotericin B and 5‐fluorocytosine, which were initiated immediately after appearance of the sign, proved to be effective, probably in association with hematologic improvement. Transbronchial lung biopsy was not only helpful in establishing a definitive diagnosis, but also suggested that an intracavitary mass could have resulted from pulmonary infarction. This experience thus showed that the sign may appear in greater frequency in mucormycosis as well as in aspergillosis, and may be useful as a clinical index for initiating antifungal therapy in immunocompromised patients.

造血器腫瘍患者に合併した緑膿菌菌血症の治療における遺伝子組換えヒト型顆粒球コロニー刺激因子 (G-CSF) の効果

The efficacy of recombinant human granulocyte colony-stimulating factor (G-CSF) in the treatment of Pseudomonas aeruginosa bacteremia in cancer patients receiving intensive chemotherapy was studied retrospectively. In 14 of the 24 episodes of P. aeruginosa bacteremia, which occurred in 23 severely neutropenic patients with hematologic malignancies during a three-year period, G-CSF was given subcutaneously or intravenously at daily doses of 75 micrograms/body to 200 micrograms/m2 of body surface. Overall, survival at one week after onset was observed in 13 patients (54%). Treatment with G-CSF, however, had no statistically significant association with one-week survival, although a favorable outcome was well correlated with an increase in the neutrophil count during therapy. On the other hand, septic shock and appropriate antibiotic therapy were the major prognostic factors. The frequency of shock was reduced by appropriate therapy, but not by G-CSF treatment. These preliminary findings thus suggested that G-CSF should not be effective in the treatment of neutropenic cancer patients with P. aeruginosa bacteremia. No adverse effects of G-CSF were observed.

TWO CASES OF AEROMONAS HYDROPHILA SEPTICEMIA ASSOCIATED WITH ACUTE LEUKEMIA

急性骨髄性白血病の2症例にAeromonas hydrophila敗血症が経験された. 1例は,緩解導入直後に発症し,他の1例は,腰筋内膿瘍が敗血巣septic focusとなつて,再発性敗血症を呈した.両例は,ほぼ同一時期に同一病棟に入院していたが,交叉感染cross-infectionはま否定された.血中抗体価の測定から,発症前に血中抗体価の上昇がみられる場台には,既存の病巣が推定され,再発予防のため,十分な抗生薬療法を行なう必要のあることが強調された.さらに,非病原性菌と考えられる本菌感染症の発症には,宿主防禦機構の減弱が重要な役割を果していることが示唆された.急性白血病における本菌敗血症は,典型的なuosocomial and opporunistic infectionと考えられる.本論文では,急性白血病に合併したA. hydrohila敗血症の2症例の提示とともに,急性白血病で本菌感染症がもつ臨床的意義を臨床細藏学の立場から論ずる.

An idiopathic skin eruption resembling a butterfly rash in a septic patient with disseminated intravascular coagulation following bone marrow transplantation.

A 31-year-old man who underwent chemotherapy and bone marrow transplantation to treat acute myeloblastic leukemia was admitted to our department complaining of high fever and hypotension. His physical examination revealed warm shock state, eruptions resembling that seen in systemic lupus erythematosus on his face and cyanosis in his fingers. We diagnosed septic shock and idiopathic skin eruption on his face. Following treatment with blood transfusion, anticoagulant, antibiotics, respirator and continuous arteriovenous hemofiltration and dialysis, the patients condition gradually improved. The eruptions on his face first observed at admission progressed with a worsening of his disseminated intravascular coagulation (DIC), and subsided with an improvement in his DIC. A biopsy of the eruption was taken and pathological findings of the eruption revealed multiple micro-fibrin depositions of the dermis. The skin necrosis in purpura fulminans often begins in the distal extremities. But our patient developed this uncommon skin eruption on his face. Patients with an idiopathic skin eruption resembling a butterfly rash in a septic patient should be considered to complicate DIC as in the present case.

TWO CASES OF ERYTHEMA NODOSUM SECONDARY TO STREPTOCOCCAL INFECTION

溶連菌感染症に続発したと考えられる結節性紅斑(EN)の2症例を経験した.両症例ともENは上気道炎に罹患後1～2週間に出現し,紅斑の出現とほぼ一致してantistreptolysin O値とantistreptokinase値の上昇がみられた.皮下結節の組織学的検索でもENの定型的組織像を呈していた.症例2では入院時に行なつた咽頭培養にてA群溶連菌8型が純培養状に分離された. PHAとstreptolysin O (SLO)の添加によるリンパ球幼若化反応を3H-thymidineのとりこみで,健康人を対照にして検討したところ, PHAによるstimulation index (SI)はENでは健康人よりも約50%低下していたが, SLOの場合にはEN症例で健康人よりもSIで1.5～3倍と高値を示したため,溶連菌感染症に続発したEN症例では, SLOに対する特異的細胞性免疫が成立していることが予想された.本症の治療はペニシリン剤と抗炎鎮痛剤の併用が効果的で,とくに重症例ではステロイドホルモンの投与が著効を呈すると考えられた.