過去12年間の胸部X線像より成立過程を観察しえた慢性壊死性肺アスペルギルス症の1例

A Case of Chronic Necrotizing Pulmonary Aspergillosis Followed up for 12 Years

　慢性壊死性肺アスペルギルス症（CNPA）は，アスペルギルス感染により，肺実質の破壊壊死が緩徐に進行して一次性空洞を形成する稀な疾患である．本症の成立過程を観察した76歳，男性例を報告する．12年前のX線写真は，両下肺野に間質性変化を軽度認めるのみであったが，5年前に右上肺野に浸潤影が出現，徐々に進行し空洞を伴う腫瘤性病変へと変化し，喘鳴を伴う呼吸困難も認めるようになった．CRP，血沈，IgG,IgEは軽度上昇，アスペルギルスのIgE-RAST高値，沈降抗体陽性．末梢血リンパ球のT・B細胞減少，NK細胞増加，気道過敏性を認めた．経気管支肺生検でアスペルギルス菌糸と壊死組織を認め，本症と診断した．本例のX線写真の経過は空洞病変が一次性であることを示しており，喘息症状，気道過敏性，IgE抗体，沈降抗体，皮膚反応からアレルギー性気管支肺アスペルギルス症（ABPA）の存在も推定され，アスペルギルス感染が同一患者にCNPAとABPAの病態を惹起したと考えた．

We report a case of a 76-year-old nonimmunocom-promised male who was diagnosed as having chronic necrotizing pulmonary aspergillosis (CNPA) from findings of a transbronchial lung biopsy (TBLB) and the time course of chest X-ray. He had received follow-up chest X-ray for 12 years since fibrotic changes were found in his bilateral lung base. Five years before the diagnosis of CPNA, new infiltrative changes appeared in the right upper lobe, then the infiltrates developed to a cavitary mass lesion with a fungus ball suggesting primary aspergilloma. Aspergil-lus species were cultured from his sputum and the TBLB specimens showed invasive aspergillus infiltration and necrotic changes of lung tissue. At the same time, he had episodes of asthmatic attacks with stridor. He had a high IgE RAST score, precipitating antibody and positive skin test reaction to aspergillus, and positive airway hypersensitivity test reaction to methacholine. The case suggested that a complication of allergic bronchopulmonary aspergillosis could occur in a similar patient with CNPA.