アムホテリシンBリポソ－ム製剤およびボリコナゾールが奏効した高齢発症のクリプトコッカス髄膜炎の1例

Cryptococcal Meningitis Successfully Treated with Liposomal Amphotericin B and Voriconazole in an Elderly Patient

はじめに

　クリプトコッカス髄膜炎は未治療では致死的な真菌感染症であり，迅速な治療が必須である^1，2）。リポソーマルアムホテリシンB（liposomal amphotericin B：L-AMB）は，発熱や腎毒性などの副作用がより少ない抗真菌薬として知られており，クリプトコッカス髄膜炎においても腎機能低下が問題となる症例において推奨されている^1）。さらにボリコナゾール（voriconazole：VRCZ）は，高い抗真菌作用を有し，侵襲性アスペルギルス症を対象としたアムホテリシンB（amphotericin B：AMPH-B）との比較試験では，有効性および安全性においてAMPH-Bより優れていることが報告されている^3）。さらに本邦のクリプトコッカス髄膜炎の治療ガイドラインでも第2選択薬に位置づけられ，今後の効果が期待されている^2）。われわれは，重症のクリプトコッカス髄膜炎症例で，L-AMBおよびVRCZが有効で独歩退院し得た貴重な症例を経験したので報告する。

Abstract

　An 81-year-old woman who had microscopic polyangiitis that was being treated with corticosteroids for 2 months was admitted to our department because of fever and clouding of consciousness.　Neurological examination showed disturbance of consciousness and nuchal stiffness.　Analysis of cerebrospinal fluid (CSF) revealed pleocytosis, low glucose level, and elevated protein levels.　On the basis of the presence of Cryptococcus neoformans in CSF, the patient was diagnosed with cryptococcal meningitis.　On the basis of established practice guidelines, liposomal amphotericin B (L-AMB) was administered to avoid the possible nephrotoxicity of amphotericin B.　After the treatment was started, the patient's condition gradually improved.　The results of CSF analysis also showed a gradual recovery.　Because the cryptococcal antigen in CSF did not disappear completely, voriconazole (VRCZ) was administered orally; subsequently, the CSF cryptococcal antigen titer gradually decreased.　During the course of the treatment with L-AMB and VRCZ, there were no severe side effects that required a change in treatment.　To the best of our knowledge, in Japan, the combination of L-AMB and VRCZ has rarely been reported to be effective for the treatment of cryptococcal meningitis.　The recovery of our patient indicates that the administration of L-AMB and VRCZ to elderly patients with cryptococcal meningitis and renal insufficiency is safe and leads to a successful outcome.

（Received: March 11,2010,Accepted: June 10,2010)