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要約 背景:刺青関連サルコイドーシスは,刺青部に生じるサルコイド様肉芽腫と全身性サルコイドーシスの症状を呈する疾患であり,ぶどう膜炎を伴うこともある。今回,刺青関連サルコイドーシスが疑われた難治性ぶどう膜炎の1例を経験したので報告する。
症例:30歳,女性。20XX年1月に発熱と右鼠径部リンパ節腫脹で当院内科を初診し,同年4月右眼痛のため眼科に初診となった。右視力低下,レーザーフレア値上昇,両隅角のテント状周辺虹彩前癒着,両眼底の雪玉状硝子体混濁を認めた。フルオレセイン蛍光眼底造影検査で両視神経乳頭過蛍光および網膜静脈からの斑状の蛍光漏出を認めた。血液検査でsIL-2Rとリゾチームは上昇,ガリウムシンチグラフィで両腋下・右鼠径部リンパ節に集積を認めた。背部刺青部の皮膚生検で刺青色素疑いの顆粒を含むサルコイド様肉芽種を認めた。右ベタメタゾン0.1%点眼とプレドニゾロン(PSL)20mg/日の内服で加療を開始し,刺青除去術を施行した。同年9月に症状の改善を認めたためPSLを中止した。同年10月に両視力低下と両黄斑浮腫を認め,右トリアムシノロンアセトニド20mgテノン囊下注射(STTA)を施行し,PSL 5mg/日内服を再開した。20XX+1年8月に右後囊下白内障に対して水晶体再建術施行した。以降も両黄斑浮腫は再燃し,STTAを複数回施行した。20XX+3年5月アダリムマブ40mg皮下注を開始し,以降黄斑浮腫の再燃はない。
結論:サルコイドーシスに伴うぶどう膜炎の原因の1つに刺青の関与がある。ステロイド治療で炎症が続く刺青関連サルコイドーシスにおいて,アダリムマブの有効性が示唆された。
Abstract Background:Tattoo-associated sarcoidosis presents with sarcoid-like granulomas in tattoos and clinical symptoms of systemic sarcoidosis, which can complicate uveitis. Here, we report a case of intractable uveitis with suspected tattoo-associated sarcoidosis.
Case:A 30-year-old woman presented to the internal medicine department of our hospital with fever and right inguinal lymphadenopathy in January 20XX, and visited the ophthalmology department with pain and vision loss in her right eye 3 months later. High laser flare values, tent-shaped peripheral anterior synechiae, and snowball-like vitreous opacity were observed in both eyes. Fluorescein angiography revealed bilateral optic nerve papillary hyperfluorescence and mottled vascular leakage. Serum soluble interleukin-2 receptor and lysozyme were elevated. Gallium scintigraphy showed accumulation in both axillary and right inguinal lymph nodes. Biopsy of her tattooed skin showed sarcoid-like granulomas including granules suggestive of tattoo pigments. She was treated with betamethasone sodium phosphate in her right eye, prednisolone(PSL), and excision of the tattoo. The PSL was tapered over 4 months with improvement of clinical symptoms. She presented with progressive vision loss in both eyes with macular edema after a month. Sub-Tenon's triamcinolone acetonide(STTA)was performed in the right eye and PSL was resumed. Cataract surgery was performed in August 20XX+1. Bilateral macular edemas recurred and multiple STTA injections were performed. In May 20XX+3 she was started on adalimumab. Since then, no recurrence of macular edema in both eyes has been observed.
Conclusion:Tattoo is a possible cause of uveitis associated with sarcoidosis. Our report suggests that adalimumab is effective in cases resistant to steroid therapy.
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