腹腔鏡による組織生検が早期診断に有用であった結核性腹膜炎の1例

A case of tuberculous peritonitis diagnosed early by laparoscopic tissue biopsy

◆要旨：審査腹腔鏡により早期の治療介入が可能であった結核性腹膜炎の1例を経験した．患者は74歳，女性．主訴は発熱．CTにて右肺尖に浸潤影，腹水，腹膜肥厚を認めた．T-SPOT.TB検査が陽性であり結核性腹膜炎を合併した肺結核症が疑われた．しかし喀痰・腹水ともに結核菌は検出されなかったため，審査腹腔鏡を施行した．腹膜にびまん性に白色結節を認め，同部位の病理組織学的検査でLanghans巨細胞を伴う類上皮性肉芽腫を認めた．このため，結核性腹膜炎と診断し，抗結核療法を開始した．結核性腹膜炎では腹水中の結核菌の証明は困難であり，審査腹腔鏡は早期診断，治療介入に非常に有用と考えられた．

　We encountered a case of tuberculous peritonitis, which was diagnosed and treated early based on laparoscopic examination. The patient was a 74-year-old woman who had fever, and computed tomography demonstrated infiltration in the right apical pulmonary region, ascites, and peritoneal thickening. The T-SPOT. TB examination results were positive; thus, pulmonary tuberculosis accompanied by tuberculous peritonitis was suspected. Because Mycobacterium tuberculosis was not detected in both the sputum and ascites, laparoscopic examination was performed. Diffuse white nodes were observed on the peritoneal membrane, and histopathological examination of the biopsied tissue of the membrane showed epithelioid cell granulomas and Langhans giant cells. Therefore, a diagnosis of tuberculous peritonitis was established and anti-tuberculosis therapy was initiated. Detecting M. tuberculosis in ascites of patients with tuberculous peritonitis is difficult ; thus, laparoscopic examination is helpful to confirm the diagnosis and initial treatment.