収縮性心膜炎が原因の心不全加療中にアジソン病の合併が判明した1例

A Case of Acute Decompensated Heart Failure Caused by Constrictive Pericarditis Complication of Addison's Disease

要旨　患者は76歳，女性．呼吸困難と下腿浮腫を主訴に近医を受診し，慢性心不全急性増悪と診断され当院入院となった．当初，左室駆出率の保たれた拡張不全が病因の心不全として加療していたが，胸部X線写真側面像と胸部CT検査での心膜石灰化から収縮性心膜炎を疑い，右心カテーテルを施行，確定診断を得た．また，全身色素沈着と心不全加療中出現した低Na血症，高K血症からアジソン病を疑い，迅速ACTH負荷試験を施行，確定診断を得た．本症例の低Na血症，高K血症はレニン・アンジオテンシン・アルドステロン系抑制薬投与により顕在化したと考えられた．収縮性心膜炎とアジソン病の合併を報告した過去の例では両者の病因を結核性と推定していたが，本症例では不明であった．

　A 76-year-old female was admitted to our hospital with the chief complaint of shortness of breath and bilateral swelling of the lower extremities. At first we made a diagnosis of heart failure with normal left ventricular ejection fraction that is, diastolic dysfunction, but chest radiogram revealed calcification of the pericardium and computed tomography revealed that the right atrium and ventricle was covered with thickened and calcified pericardium, "armored heart". Catheterization of the right side of the heart demonstrated a dip and plateau pattern of the right and left ventricular pressure wave form and equalization of the right and left diastolic pressure. Constrictive pericarditis was diagnosed. Systemic pigmentation and electrolytic disorder during the treatment of acute decompensated heart failure made us suspect of the complication of Addison's disease. Rapid ACTH stimulation test confirmed the diagnosis of Addison's disease. In developed countries, because tuberculosis is not a common cause of constrictive pericarditis and Addison's disease, no cause had been identified. Administration of rennin-angiotensin-aldosterone inhibitors for acute decompensated heart failure led to electrolytic disorder.