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Neurological Surgery No Shinkei Geka Volume 42, Issue 2 （February 2014）

Neurological Surgery 脳神経外科 42巻2号（2014年2月発行）

Japanese English

症例

免疫正常者のCryptococcus neoformans var. gattii髄膜脳炎によるcryptococcomaに対し外科的切除術が奏功した1例 Cryptococcus Neoformans Var. Gattii Meningoencephalitis with Cryptococcoma in an Immunocompetent Patient Successfully Treated by Surgical Resection 稲田拓 ¹ , 今村博敏 ¹ , 川本未知 ² , 関谷博顕 ² , 今井幸弘 ³ , 谷正一 ¹ , 足立秀光 ¹ , 石川達也 ¹ , 峰晴陽平 ¹ , 浅井克則 ¹ , 池田宏之 ¹ , 小倉健紀 ¹ , 柴田帝式 ¹ , 別府幹也 ¹ , 阿河祐二 ¹ , 清水寛平 ¹ , 坂井信幸 ¹ , 菊池晴彦 ¹ Taku INADA ¹ , Hirotoshi IMAMURA ¹ , Michi KAWAMOTO ² , Hiroaki SEKIYA ² , Yukihiro IMAI ³ , Shoichi TANI ¹ , Hidemitsu ADACHI ¹ , Tatsuya ISHIKAWA ¹ , Yohei MINEHARU ¹ , Katsunori ASAI ¹ , Hiroyuki IKEDA ¹ , Takenori OGURA ¹ , Teishiki SHIBATA ¹ , Mikiya BEPPU ¹ , Yuji AGAWA ¹ , Kanpei SHIMIZU ¹ , Nobuyuki SAKAI ¹ , Haruhiko KIKUCHI ¹ ¹神戸市立医療センター中央市民病院脳神経外科 ²神戸市立医療センター中央市民病院神経内科 ³神戸市立医療センター中央市民病院臨床病理科 ¹Department of Neurosurgery, Kobe City Medical Center General Hospital ²Department of Neurology, Kobe City Medical Center General Hospital ³Department of Clinicopathology, Kobe City Medical Center General Hospital キーワード： Cryptococcus neoformans var. gattii , cryptococcoma , cryptococcosis , fungal meningitis , surgical treatment Keyword: Cryptococcus neoformans var. gattii , cryptococcoma , cryptococcosis , fungal meningitis , surgical treatment pp.123-127

発行日 2014年2月10日 Published Date 2014/2/10

DOI https://doi.org/10.11477/mf.1436102178

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Ⅰ．はじめに

　クリプトコッカス症は，主に呼吸器と中枢神経系に病変を作ることが多い真菌感染症である．本邦ではCryptococcus neoformans（C. neoformans）が主な原因である．今回，われわれは免疫正常者が本邦では稀なCryptococcus neoformans var. gattii（C. gattii）によるクリプトコッカス髄膜脳炎を発症し，その治療中に酵母菌腫（cryptococcoma）を形成し抗真菌薬の全身投与および髄腔内投与に抵抗性であり，開頭摘出術が奏功した1例を経験したので報告する．

　Cryptococcosis is a fungal infection, which mainly invades the lungs and central nervous system. In Japan, most cases of cryptococcosis are caused by Cryptococcus neoformans（C. neoformans). Until now, only three cases which the infectious agent was Cryptococcus neoformans var. gattii（C. gattii）have been reported. As compared with cryptococcosis caused by C. neoformans, which is often observed in immunocompromised hosts, cryptococcosis caused by C. gattii occurs predominantly in immunocompetent hosts and is resistant to antifungal drugs. Here, we report a case of refractory cerebral cryptococcoma that was successfully treated by surgical resection of the lesions.

　A 33-year-old man with no medical history complained of headache, hearing disturbance, and irritability. Pulmonary CT showed a nodular lesion in the left lung. Cerebrospinal fluid examination with Indian ink indicated cryptococcal meningitis, and PCR confirmed infection with C. gattii. C. gattii is usually seen in the tropics and subtropics. Since this patient imported trees and soils from abroad to feed stag beetles, parasite or fungal infection was, as such, suspected. Although he received 2 years of intravenous and intraventricular antifungal treatment, brain cryptococcomas were formed and gradually increased. Because of the refractory clinical course, the patient underwent surgical resection of the cerebral lesions. With continuation of antifungal drugs for 6 months after the surgeries, Cryptococcus could not be cultured from cerebrospinal fluid, and no lesions were seen on MR images. If cerebral cryptococcosis responds poorly to antifungal agents, surgical treatment of the cerebral lesion should be considered.