大腸結核との鑑別が困難であった大腸Crohn病の1例

A Case of Crohn's Colitis Which was Difficult to Differentiate from Tuberculosis

要旨　患者は72歳の男性で，主訴は水様便と発熱，ツ反は強陽性を呈した．初回入院時の注腸および内視鏡所見は，下行～上行結腸にかけての粘膜集中を伴う類円形・不整形潰瘍である．縦走潰瘍やcobblestone像は認めていない．潰瘍は幾分輪状傾向を呈し，この時点で大腸結核が疑われ抗結核剤投与が行われた．3か月後，病状・注腸所見は改善し治療に反応したと考えられた．その後の十分な抗結核療法にもかかわらず，再燃を2回繰り返し内科的治療に次第に反応しなくなったので，初発より約4年後に手術が施行された．本症例は，高齢，ツ反強陽性，抗結核剤に対する反応および初回の注腸・内視鏡所見などから大腸結核がまず考えられたが，経過をみるうちに縦走潰瘍，cobblestone像や腸管の狭小化が顕著となり，手術標本の肉眼・組織所見からも最終的には大腸Crohn病と考えられた．

　A 72-year-old male was admitted to our hospital with complaints of watery stool and fever. His tuberculin reaction was strongly positive with induration. Barium enema and colonoscopy at the first admission showed oval and irregular-shaped ulcers with the fold convergency and fine mucosal nodularity at the ulcer margin in the descending and transverse colon (Fig. 1). Longitudinal ulcers or cobblestone appearance, however, were not seen. These findings were most suggestive of large intestinal tuberculosis.

　His symptoms and abnormalities on barium enema improved once after the administration of antituberculosis agents. However, his symptoms recurred twice in spite of the sufficient dosages of antituberculosis agents and finally became refractory to the medication. Repeat barium enema and colonoscopy revealed that longitudinal ulcers, cobblestone appearance and narrowing developed gradually during his clinical course. Based on these findings of repeat barium enema and colonoscopy, Crohn's colitis was diagnosed.

　A subtotal colectomy was performed four years after the onset of symptoms. Macroscopic and microscopic findings of the resected specimen were compatible with that of Crohn's disease.