突然の胸部圧迫感を主訴として来院した結核性心外膜炎の1例

A Case of Tuberculous Pericarditis and Sudden Chest Oppression without Significant Inflammatory Reaction

　患者は74歳，男性で，突然の胸部圧迫感と呼吸困難を主訴に来院した．胸部X線写真で縦隔と心陰影の拡大があり，心エコーで大量の心嚢液を認めた．また，胸部CTでは大動脈解離はなく心膜の軽度の肥厚と著明な心嚢液を認めた．心タンポナーデの診断で心嚢ドレナージ後，呼吸困難は著明に改善した．心嚢液は血性でアデノシンデアミナーゼが43.9IU／lと高値であった．再度，心タンポナーデの増悪のため胸腔鏡下にドレナージと心膜生検，縦隔リンパ節生検を施行した．縦隔リンパ節生検で乾酪壊死巣が認められ，結核性心外膜炎と診断した．抗結核療法とステロイドの併用療法を開始したところ，それ以降心嚢液の貯留は認められなかった．結核性心外膜炎は抗結核療法の普及以来稀な疾患である．肺野病変や全身炎症所見が乏しくても，大量の心嚢液やリンパ節腫大を呈する例は結核性心外膜炎を考慮し，組織学的検索を含めた精査が必要と考えた．

A 74-year-old male was admitted to our hospitalbecause of sudden chest oppression and dyspnea. Onchest X-ray film, cardiac shadow and mediastinal spacewere enlarged. Large amounts of pericardial effusionand pericardial thickening were confirmed by echocar-diography and chest computed tomography, and thendiagnosed as cardiac tamponade. Pericardial effusionbloody, and adenosin deaminase level in the effusion waselevated without inflammatory reaction. Since pericar-dial effusion increased again, pericardial and medias-tinal lymph node biopsy was undertaken, and revealedtypical granuloma formation with caseous necrosis. Thecase was diagnosed as tuberculous pericarditis. Accord-ingly, combined oral administration of antituberculardrugs with prednisolone were started and continued forthree months. Thereafter, the patient was free fromsymptoms and without accumulation of pericardialeffusion. These findings suggest that tuberculous pericar-ditis should be considered in a patient complaining ofsudden chest discomfort due to massive pericardialeffusion, even without significant inflammatory reaction.