アフタ様病変のみで発症し4年6か月間経過をみたCrohn病の1例

Crohn's Disease Followed up for Four Years and Six Months with Only Aphthoid Lesions at the Onset, Report of a Case

要旨　51歳，女性．咽頭痛，発熱，下痢で発症．裂肛を認めた．入院時検査で異常値を示したものは白血球増多(13,200/μl)，貧血(Hb9.1g/dl)，低アルブミン血症(2.7g/dl)，CRP(3＋)，血沈亢進(50mm/1時間)であった．初回の注腸X線検査で直腸，盲腸を除く大腸に無数のアフタ様病変を認め，小腸X線検査でも回腸にアフタ様潰瘍を認めた．大腸内視鏡検査でもアフタ様病変を認め，S状結腸からの生検標本内に非乾酪性類上皮性肉芽腫を認めた．成分栄養療法を開始し，副腎皮質ホルモン，salazosulfapyridine投与で臨床症状は速やかに消失し，検査所見も改善した．初回検査から9週間後のX線像では，大腸粘膜面に粘膜ひだ集中と炎症性ポリープを認め，治癒像を示した．その8か月後のX線像ではリンパ濾胞の増悪がみられ，更に2年後のX線像ではリンパ濾胞増悪の所見が存続した．そして，その1年7か月後，初回から4年6か月後の注腸X線像ではアフタ様潰瘍の再発を認めた．また，小腸に短い縦走潰瘍，偏側性の壁変化から成るCrohn病の特徴的所見が認められた．この症例をはじめ，報告された同様の症例のX線所見をみると，緩解したCrohn病の再燃の前ぶれとしてアフタ様潰瘍が再発している．

　A 51-year-old woman presented complaints of throat pain, fever and diarrhea. Anal fissures were found in the rectal examination. Laboratory examinations revealed leucocytosis (13,200/μl), slight anemia (Hb 9.1 g/dl), hypoalbuminemia (2.7 g/dl), positive CRP and elevated erythrocyte sedimentation rate.

　Initial barium enema showed numerous aphthoid ulcers and discrete ulcers scattered throughout the colon had spared the rectum and the cecum. X-ray examination of the small intestine demonstrated aphthoid ulcers in the distal ileum. Colonoscopy showed aphthoid ulcers on the mucosal surface of the colon. Histological examination of the biopsy specimen from the sigmoid colon showed non-caseating epithelioid cell granuloma.

　The patient was treated with elemental diet alimentation and administration of prednisolone and salazosulfapyridine. The clinical symptoms disappeared rapidly and laboratory data improved to normal. Repeated barium enema nine weeks after the initial examination showed only scars with mucosal convergency and inflammatory polyposis. The next barium enema eight months later showed enlarged lymph follicles scattered throughout the entire colon, and two years later, the same findings were observed. The last radiological examinations, four years and six months after the initial examinaton, showed the recurrence of aphthoid ulcers in the colon. X-ray of the small intestine revealed characteristic findings of Crohn's disease such as longitudinal ulceration and eccentric rigidity.

　In this case, just as in other reported cases, the radiographic evidence suggests that a reactivation of quiescent Crohn's disease was heralded by a reoccurrence of aphthoid ulcers.