免疫抑制療法により冠動脈病変が改善した結節性多発動脈炎の1例

A Case of Coronary Arterial Lesions Complicated with Polyarteritis Nodosa,Improved by Treatment with Immunosuppressive Therapy

要旨　患者は52歳，男性．2003年6月頃より咳嗽，微熱，全身倦怠感，体重減少，下肢筋肉痛，睾丸痛など自覚．同年10月初旬に胸痛を認めたが放置していた．精査加療目的に11月6日当科入院．炎症所見とMPO-ANCA上昇を認めた．心電図ではV_3-5で異常Q波と陰性T波を認めた．冠動脈造影で右冠動脈末梢に75％狭窄と途絶像を，左前下行枝中間部から末梢に高度狭窄を伴うびまん性狭窄を，対角枝にびまん性狭窄と途絶像を認めた．また，左回旋枝中間部から末梢にもびまん性狭窄病変を認めた．左心室造影では前壁・側壁領域から心尖部はakinesis，下壁領域はhypokinesisを呈し，EFは39%と低下していた．201Tl心筋シンチでは前壁から心尖部にかけて欠損像を認めた．心筋梗塞を合併した結節性多発動脈炎と診断しプレドニゾロン60mg/日とシクロフォスファミド50mg/日を開始し，自覚症状および炎症反応は徐々に改善した．約8カ月後の冠動脈造影検査では冠動脈のびまん性狭窄病変は改善し，EFは52%に上昇した．

Summary

　The patient was a 52-year-old male. In June 2003, cough, slight fever, general malaise, weight loss, muscular pain in the legs, and testicular pain occurred. In early October 2003, hest pain developed, but the patient did not consult a physician. On November 6, the patient was admitted to our department for detailed examination and treatment. Inflammation and an increase in the level of MPO-ANCA were noted. Electrocardiography showed abnormal Q waves and negative T waves in leads V3 to V5. Coronary angiography revealed 75% stenosis and obstruction in the peripheral right coronary, marked diffuse stenosis in the intermediate to peripheral regions of the left anterior descending artery, and diffuse stenosis with obstruction in the diagonal branches. Furthermore, diffuse stenosis was observed in the intermediate to peripheral regions of the left circumflex artery. Left ventriculography revealed akinesis from the anterior/lateral area to the apex and hypokinesis in the inferior wall region. Ejection fraction(EF) was 39%. 201Tl myocardial scintigraphy showed a defect involving the anterior wall extending to the apex. A diagnosis of polyarteritis nodosa(PN) was made based on the symptoms and angiographic findings, and administration of 60 mg/day prednisolone and 50 mg/day cyclophosphamide was initiated. The symptoms and inflammatory response gradually improved. Coronary angiography 8 months after the start of treatment showed improvement of diffuse coronary stenosis, and EF was increased to 52%.