経皮的心肺補助システムにより低酸素脳症を予防し得たと考えられる再発性脳梗塞合併抗リン脂質抗体陽性肺梗塞の1例

An effective case of percutaneous cardiopulmolnary support that was used in order mainly to prevent brain hypoxia due to puhnonary infarction associated with Lupus anticoagulant that had recurrant cerebral infarction

　症例は61歳男性，主訴は咳，発熱，既往歴に高血圧，再発性脳梗塞，家族歴に特記歴なし．現病歴では1996年12月7日頃より咳，発熱出現，1997年1月3日頃より呼吸困難も出現，肺炎の疑いで2月10日当院入院．身体所見では体温38.2℃，脈拍は108／分，呼吸数は30／分，右下肺に呼吸音の減弱，四肢にはチアノーゼあり．血液検査所見では貧血，血小板減少，赤沈の亢進，APTTは44.6秒と延長，CRP 15.9mg／dl，胸水は血性，抗カルジオリピン抗体陽性であった．抗生物質治療を行うが2月18日トイレ歩行後より起座呼吸となり意識消失し肺梗塞と診断，人工呼吸器管理行うも低酸素状態は改善せず，経皮的心肺補助システムにて低酸素状態は改善し，既往の脳梗塞への悪影響は回避できた．本例はその原因として抗リン脂質抗体が関与している可能性が疑われた．本例の動脈血の酸素化には経皮的心肺補助システムが有効であり脳梗塞の悪化を予防し得たと考えられる．

A 61-year-old man was admitted to our hospital for investigation of progressive cough, fever. dvspnea and pleural effusion over the previous 2 months. Firstly we suspected pneumonia because of the consolidation on the right lower lobe in chest X ray film, so we adminis-trated some antibiotics. But his synptoms worsened and on the 8th day after admission, the loss of conciousness and respiratory arrest occurred suddenly. The pulmo-nary arterial pressure on data obtained by a Swan Ganz catheter rose to 74/18mmHg though the pulmonary capillary wedge pressure was normal, so we diagnosed his illness as pulmonary infarction. As the severe hypox-ia was not improved in spite of controlled ventilation (F_IO₂: 0.8, VC: 8l/min, RR: 20/min), the per-cutaneous cardiopulmonary support (PCPS) system was used in order to mainly prevent brain hypoxia, because he had experienced cerebral infarction (8 and 5 years previously). By the use of PCPS, his hypoxia and symp-toms improved quickly. The pulmonary arterial pres-sure also fell to 50/16mmHg. Pulmonary thrombosis as a cause of pulmonary infarction was ascertained bychest CT, pulmonary perfusion scintigraphy and pulmo-nary arteriography. As the decrease of platelet counts, the prolongation of APTT (44.6sec) and the positive finding of IgG anti-cardiolipin antibody were observed, we finally diagnosed his illness as pulmonary thrombosis associated with lupus anti-coagulant. In this case, we considered that PCPS was effective against heart and pulmonary failure and that the use of PCPS was timely. This case was treated with intravenous administration of heparin. urokinase and long-term warfarin p. o.. No recurrence has been observed for 8 months, during which thrombolytic therapy with warfarin has been used.