パニペネム大量投与が著効した多発脳膿瘍の1例

A Case of Multiple Brain Abscess Effectively Markedly Responded to High Dose Panipenem/Betamipron Administration

要旨　生来健康な54歳女性。頭痛，嘔気，嘔吐を主訴に来院し，髄液検査にて多形核球優位の細胞数増多と糖低下を認め，細菌性髄膜炎の診断で入院となった。肺炎の合併あり，頭部CTで右大脳半球白質に淡い低吸収域を認めた。入院後，アンピシリンとセフォタキシムの投与を開始し，入院3日目，髄液細胞数は低下したが，意識レベルの低下，項部硬直の増悪を認めた。入院7日目，髄液細胞数の再上昇あり，パニペネム/ベタミプロン4g/dayに変更した。入院10日目，髄液細胞数は改善したが，入院12日目，意識レベルはさらに傾眠傾向へと悪化した。頭部CTとMRIで多発脳膿瘍および水頭症を認めたため，8g/dayへ増量した。以後症状，髄液・MRI所見ともに改善，入院69日目，退院となった。β-ラクタマーゼ産生菌が増加している今日，カルバペネム系抗菌薬の初期投与を検討する価値があると考えた。本例では各種培養にて起因菌は同定できなかった。

A 54-year-old, previously healthy female experienced headache, nausea and vomiting, and consulted our hospital regarding her symptoms. Her cerebrospinal fluid （CSF） showed leukocytosis with polymorphonucleosis and hypoglycemia, thus she was diagnosed with bacterial. She admitted to our hospital and combination therapy of ampicillin and cefotaxime was started. CSF and blood cultures was negative. On the third hospital day, despite a decrease in her CSF cell count, her consciousness level decreased and neck stiffness worsened. On the seventh hospital day, the CSF cell count increased again, and we changed antibiotics to panipenem/betamipron （PAPM/BP） at 4g/day. On the tenth hospital day, the CSF cell count decreased, but by the twelfth hospital day her consciousness had deteriorated to a drowsy state. Brain CT and MRI revealed multiple brain abscesses and hydrocephalus. We increased the dose of PAPM/BP up to 8g/day, and her neurological, CSF and brain MRI findings subsequently improved. The patient was discharged from our hospital on the sixty-ninth hospital day. As the frequency of beta-lactamase-producing bacteria is currently increasing, carbapenems should be considered as first choice of antibiotics for the initial treatment of multiple brain abscess.

（Received : November 11, 2004）