抗結核薬による診断的治療が奏効した小腸多発潰瘍の1例

Multiple Small Bowel Ulcers in the Small Bowel Improved by Diagnostic Treatment Using an Antituberculous Agent, Report of a Case

要旨●患者は60歳代，女性．下痢，食欲不振にて受診．腹部CT検査で腸間膜リンパ節腫大，腸管壁肥厚を認め，大腸内視鏡検査で回腸末端のびらんを認めた．小腸カプセル内視鏡検査およびバルーン内視鏡検査で中部空腸〜回腸末端までほぼ全域で多発する網目状潰瘍を認めた．生検では陰窩膿瘍を認めていた．Crohn病としてステロイド薬が投与されたが，病状悪化，血中サイトメガロウイルス（CMV）アンチゲネミアが陽転化し，CMV腸炎の診断で，ガンシクロビルが投与されたが，潰瘍治癒は得られなかった．結核菌，乾酪性肉芽腫は未検出，抗結核特異INF-γ陰性であったが，腸結核の可能性を考慮し，抗結核薬による診断的治療を行った．4か月後に行った小腸内視鏡にて小腸潰瘍の消失を確認した．

　A woman in her sixties with severe diarrhea and loss of appetite was admitted to our hospital. Computed tomography showed swelling of the mesenteric lymph nodes and thickening of the intestinal tract wall. Colonoscopy showed erosion of the terminal ileum. We performed capsule and balloon enteroscopy, and multiple meshed ulcers were observed from the middle jejunum to the terminal ileum. Biopsy of the terminal ileum erosions showed crypt abscesses. At first, Crohn's disease was suspected, and steroids were administered. However, the patient's condition worsened. Cytomegalovirus antigen levels were found to be positive in the blood ; therefore, cytomegalovirus enteritis was diagnosed. Although the patient was administered ganciclovir for 2 weeks, its effects were insufficient. There was no evidence of tubercle bacilli or a caseous granuloma ; Mycobacterium tuberculosis-specific INF-γrelease assay was also negative. Therefore, intestinal tuberculosis was suspected, and diagnostic treatment with an antituberculous agent was initiated. We observed the disappearance of the small intestinal ulcers using balloon enteroscopy 4 months after the treatment.