診断に苦慮した全身浮腫の1例

A Case of Massive General Edema due to Constrictive Pericarditis which was Hard to Diagnose

要旨　患者は66歳，男性．全身浮腫，息切れを主訴に複数の病院に入院し精査するも確定診断に至らなかった．当科入院後も全身浮腫の原因疾患として癌・結核・ネフローゼ症候群・膠原病などを鑑別に精査を行ったがやはり確定診断に至らず．心臓カテーテル検査を当院で再検し，右室圧波形はdip and plateau pattern，右房圧は平均で31mmHgと高度上昇を認め，収縮性心膜炎と確定診断した．当院心臓血管外科にて心膜剝離術施行し，剝離心膜は約7mmで心囊液は認めず，病理学的所見でも特異的所見を認めず，特発性収縮性心膜炎と診断した．手術経過は良好で，体重も術直前94.2kgから60.3kgまで減少し独歩退院した．石灰化を伴わない特発性収縮性心膜炎の確定診断は困難な場合が多い．原因不明の右心不全の際には鑑別疾患として常に念頭に置き，疑いがあれば右心系カテーテルを迷うことなく行うことが必要である．

　A 66-year-old man was admitted to our hospital due to massive general edema and shortness of breath. Several physicians he visited previously carried out examinations including catheterization, but failed to clarify the cause of the edema. After admission, collagen disease, renal disease, and some other possible disorders were excluded. Right heart failure was obvious on admission and was rapidly getting worse day by day. The patient's body weight increased from 80 kg to 94 kg in 30 days despite sufficient diuretics. Cardiac catheterization exhibited a dip and plateau pattern of the right ventricular pressure wave form and highly elevated right ventricular systolic pressure. This led to the diagnosis of constrictive pericarditis. Cardiolysis surgery was performed, followed by an excellent post-operative clinical course. His weight dropped from 94 kg to 60 kg at discharge which is his standard weight. This case suggests that in the case of unidentified right heart failure, constrictive pericarditis should be taken into consideration as a differential diagnosis.