異所性骨化を合併しリハビリテーション治療と薬物治療で屋内歩行自立となった重症COVID-19の1例

Patient with Heterotopic Ossification Post-SARS-CoV-2 Infection Regained Ability to Walk Independently Indoors after Rehabilitation and Drug Therapy : A Case Report

はじめに

　新型コロナウイルス（severe acute respiratory syndrome coronavirus 2：SARS-CoV-2）は，全世界に拡散し，医療体制，経済活動，社会生活に多大な影響を与え，多くの感染者や死亡者をもたらしている．このような状況において，新型コロナウイルス感染症（coronavirus disease 2019：COVID-19）に伴うさまざまな合併症や後遺症が報告されている．合併症としては急性呼吸窮迫症候群，心筋炎，肺塞栓症，脳梗塞などで，後遺症としては息切れ，記憶障害，味覚障害，嗅覚障害，脱毛，筋力低下，倦怠感，抑うつなどが報告されている¹⁾．また，軽症例では日常生活動作（activities of daily living：ADL）に障害を残さず軽快する場合が多いが，酸素投与が必要な中等症例，人工呼吸器装着や体外式膜型人工肺（extracorporeal membrane oxygenation：ECMO）治療が必要な重症例では，身体活動が制限されることで，後遺症として体幹や四肢の筋力低下が生じ，ADLの低下をきたす場合がある．このようにADLが低下した症例では，感染症改善後にさらなるリハビリテーション治療の継続が必要となってくる．今回われわれは，異所性骨化を合併した重症COVID-19症例においてリハビリテーション治療と鎮痛剤および骨吸収抑制剤投与による薬物治療により屋内歩行が自立するまでに改善した1例を経験したので報告する．

　なお，本症例の報告にあたっては，患者本人へ説明を行い書面で同意を得ている．

Abstract　A 31-year-old woman infected with severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) at 33-weeks pregnant was subject to cesarean delivery due to a worsening respiratory condition. On the fourth day of illness, the patient was placed on a ventilator, with extracorporeal membrane oxygenation (ECMO) treatment initiated on the ninth day. Passive range of motion (ROM) training started on the day 33 of illness. She was weaned off ECMO on day 55 of illness and taken off of the ventilator on day 8. The tracheostomy tube was replaced with a speech cannula on day 87 of illness, at which time the patient began to complain of pain during passive ROM training. Plain X-ray photography and computed tomography (CT) showed ossification around the bilateral shoulder and hip joints, as well as on medial thighs, accompanied by an alkaline phosphatase (ALP) value of 942 U/L. She was subsequently diagnosed with heterotopic ossification, after which passive ROM training was changed to protective ROM training, in addition to treatment with indomethacin farnesyl and etidronate disodium. The patient was transferred to our hospital on day 122 of illness for the purpose of continuing rehabilitation. On day 155 of illness, ossification decreased on the medial thighs, according to CT. She was able to walk independently indoors and was discharged home on day 181 of illness. This case demonstrates the importance of checking the ALP levels and palpating the periarticular area in patients infected with SARS-CoV-2 before initiating passive ROM training, as well as being aware of any pain experienced during training. In the case of any abnormalities, assessing the ossification around the joints of extremities by imaging examination is a priority.