抗真菌薬に対する薬剤アレルギーを生じた真菌性眼内炎の1例

Fungal endophthalmitis in a case allergic to antifungal medications

要約　45歳男性が2週間前からの両眼飛蚊症と霧視で受診した。その数週前に直腸異物に対して手術を受け，経静脈高カロリー栄養（IVH）が行われていた。7年前にペニシリンアレルギーがあった。矯正視力は右0.9，左0.7で，硝子体混濁と眼底の白色病変が両眼にあり，真菌眼内炎第2期と診断した。フルコナゾールの点滴と内服で視力が回復したが，中毒性表皮壊死症が出現した。左眼病変が悪化し，ミコナゾールの点滴を開始した。8日後に薬疹が生じ，イトラコナゾール内服に変更した。40日後に肝機能が生じ，アムホテリシンB点滴に切り替えた。その17日後に低カリウム血症と血管炎が生じ，これを中止した。経過中に第3b期で手術を行った左眼は0.3，第4期で手術を行った右眼は手動弁の最終矯正視力であった。全身投与した4種の抗真菌薬すべてに薬剤アレルギーないし副作用が生じた症例である。

Abstract.　A 45-year-old male presented with blurring in both eyes since 2 weeks before. He had received abdominal surgery shortly before followed by intravenous hyperalimentation（IVH）. He had been found to be allergic to penicillin 7 years before. His visual acuity was 0.9 right and 0.7 left. Both eyes were diagnosed with fungal endophthalmitis stage 2. The visual acuity improved following intravenous and peroral fluconazole but the medication had to be discontinued due to toxic epidermal necrosis. Intravenous miconazole was started after recurrence of endophthalmitis. It had to be switched to peroral itraconazole 8 days later due to drug eruption. Liver dysfunction developed 40 days later,necessitating switching to intravenous amphotericin B. It had to be discontinued 17 days later because of hypokalemia and vasculitis. Both eyes had received vitrectomy during the above period. The final visual acuity was hand motion right and 0.3 left. This case is unique in having manifested allergy or complications to four antifungal medications.