内視鏡下生検で乾酪壊死巣を伴う類上皮肉芽腫が認められた胃結核の1例

Gastric Tuberculosis Diagnosed by Endoscopic Biopsy, Report of a Case

要旨　患者は48歳，男性で，3年前より糖尿病を指摘されていた．心窩部痛，咳嗽を主訴として来院し，右上肺野の浸潤陰影および胃体中部から前庭部にかけての大小不同の不整形潰瘍の多発が認められた．喀痰より結核菌が検出され，胃内視鏡下生検で乾酪壊死巣を伴う類上皮肉芽腫が認められたため，糖尿病を基礎疾患とした肺結核に合併した胃結核と診断した．インスリンによる糖尿病のコントロールと，抗結核剤と抗潰瘍剤の併用により6か月後には潰瘍は完全に治癒した．

　In Japan, only thirteen cases of gastric tuberculosis have been diagnosed by endoscopic biopsy, and easeous necrosis was recognized in only four of these cases. It has been proved that diabetes mellitus is one of the risk factors of M. tuberculosis infection. We successfully diagnosed and treated a case of pulmonary and gastric tuberculosis with the underlying disease of diabetes mellitus without surgical intervention.

　A 48-year-old man was admitted to our hospital complaining of epigastralgia and cough. Past history revealed that he had been diagnosed as having diabetes mellitus three years before, but had been prescribed no medication. Chest x-ray film showed pathologic infiltration in the upper portion of the right lung. Radiographic and endoscopic examinations of the stomach revealed multiple irregularly-shaped ulcers in the corpus, angulus and antrum. In the endoscopic biopsy specimens taken from two of these ulcers, epithelioid granuloma with Langhans giant cells were recognized. Culture of the sputum for acid-fast bacilli yielded Mycobacterium tuberculosis.

　The diagnosis of gastric and pulmonary tuberculosis with diabetes mellitus was established, and administration of antituberculosis drugs (SM, INH, RFP, EB) and subcutaneous injection of insulin were initiated. Serum glucose level was soon normalized. A follow-up study performed three months later showed a resolution or healing of gastric ulcers. Histological findings of the biopsy specimen taken from one of the healing stage ulcers revealed epithelioid granuloma with easeous necrosis. Six months later, chest x-ray film showed extreme improvement. Endoscopic examination revealed that gastric ulcers were completely healed, and epithelioid granuloma was not detected in the biopsy specimen.