腸管病変の高度急性期像と思われる全周性潰瘍を形成した回盲部結核症の1例

Ileocecal Tuberculosis Presenting as an Atypical Girdle Ulcer Typically Recognized as Severe, Acute-phase Intestinal Tuberculosis, Report of a Case

要旨●患者は60歳代，男性．3週間持続する右下腹部痛と発熱のため当院へ紹介され入院した．血液検査で炎症所見と肝胆道系酵素の上昇，CT検査で回腸終末の限局性全周性の壁肥厚を認めた．下部消化管内視鏡検査では回盲弁から盲腸腸間膜側にびらんの集簇と帯状の顆粒状粗糙粘膜がみられ，回盲弁は開大し，回腸終末にかけて全周性の潰瘍性病変が連続していた．注腸X線造影検査では回腸終末の潰瘍性病変は口側の境界が明瞭で，辺縁に厚みを有していた．生検で上皮下ならびに潰瘍底に小型肉芽腫の多発とZiehl-Neelsen染色像で多数の桿状抗酸菌を認め，培養で結核菌が同定された．腸結核の像としては境界明瞭な全周性潰瘍の辺縁に厚みを有し，近傍に萎縮瘢痕帯を伴わない点が非典型的であり，滲出性肉芽に多数の抗酸菌が確認されたことからも腸管病変の高度急性期の所見と考えられた．

　A 60-year-old male was referred to our hospital with a three-week history of fever, weight loss, and right, lower quadrant pain. Blood testing showed marked elevation of hepatobiliary enzymes, and moderate inflammation was observed. Computed tomography revealed diffuse thickening of the terminal ileum through the cecum. A barium enema study revealed that the oral margin of the ileal ulcerative lesion was sharp and the surrounding mucosa was slightly elevated. Endoscopic examination showed a girdle-shaped, coarse, granular surface with multiple aggregated erosions surrounding the deformed ileocecal valve and ulcerations over the entire circumference of the terminal ileum. Biopsy specimens of the ulcerative lesion revealed severe inflammation with multiple epithelioid granulomas, and numerous bacilli were observed on Ziehl-Neelsen staining. The culture of the biopsy specimens detected Mycobacterium tuberculosis. X-ray and endoscopic findings did not show the typical characteristics of intestinal tuberculosis, including healed ulcer scars, mucosal atrophy, and intestinal shortening. The findings in this case were suggestive of severe, acute-phase intestinal tuberculosis.