壊死性筋膜炎の所見を認めなかった劇症型A群連鎖球菌感染症（TSLS/toxic shock-like syndrome）の1例

Toxic Shock-like Syndrome without Necrotizing Fasciitis. Case Report

　今回われわれは早期の減張切開によって救命しえた，壊死性筋膜炎を伴わない劇症型A群連鎖球菌感染症（TSLS）を経験したので報告する．患者は感冒様症状が出現した翌日にプレショック状態に陥り，当科ICUに搬送された．右下肢の壊死性筋膜炎が疑われ，緊急に減張切開を行った．手術中の所見から壊死性筋膜炎は否定されたが，術中採取した浸出液の培養でA群連鎖球菌が検出された．術後抗生剤を変更し，炎症所見，血圧の改善を認めた．本症例は壊死性筋膜炎の所見を認めないTSLSであったが，手術により病巣確認，減圧，検体採取ができ，その後の治療に役立った．また，下肢筋肉内圧上昇から生ずる二次障害を予防することができた．本症は特別な基礎疾患のない患者においても病態が急速に進行し，迅速な治療を行わなければ極めて致死率が高い疾患であるため，化膿性軟部組織炎に全身状態の悪化がみられた時点で早急に手術に踏み切ることが重要である．

　Toxic shock-like syndrome (TSLS) is characterized by rapid progression in symptoms resulting in shock even in patients with no underlying illness. Mortality is very high without prompt treatment. We report a case of TSLS successfully treated using immediate fasciotomy. The patient, who had a fever and a precursory “flu-like” illness, went into preshock the next day, ending up in a hospital ICU. We suspected necrotizing myositis and conducted emergency surgery including fasciotomy and debridement. During surgery, we found no evidence of necrotizing myositis in the soft tissues, but isolated group A streptococcal infection by affusion culture during surgery. The patient progressed steadily postoperatively, with muscle inflammation and blood pressure improving dramatically. On hospital day 17, she was transferred to her original hospital. TSLS is often accompanied by necrotizing myositis requiring swift surgical treatment. While our case had no necrotizing myositis, we consider the surgical approach very valuable. For this reason, we conducted decompression during surgery, confirming the focus and extracting effusion. These techniques helped prevent the development of necrotizing myositis and enable us to choose the most appropriate antibiotic. Given rapid symptom progression and the high mortality involved, it is important to consider emergency surgery when general conditions worsen in the presence of suppurative inflammation of the soft tissues.