BCG腎盂内注入療法にて敗血症性ショックを生じた1例

Abstract

76歳女.主訴は不正出血.膀胱鏡検査にて多発する乳頭状膀胱腫瘍を認めた.硬膜外麻酔併用全身麻酔下に膀胱全摘除術を施行し, 術後分腎尿細胞診にて右はclass I, 左はclass IIIaであり, 術中左尿管断端にCISの伸展を認める結果であったため, 左尿管腫瘍残存の可能性が高いと考え, BCG腎盂内注入療法を施行した.その後, 悪寒戦慄, 嘔気, 嘔吐, 左腰背部痛, 38.6℃の発熱が出現し, 直ちに補液, MEPM 0.5g点滴静注を開始した.6時間後に血圧68/44mmHg, 脈拍170/分, 四肢末梢が温かく敗血症性ショックと考えられる状態となった.エンドトキシン吸着カラムを用いて吸着療法を施行し, ショックから離脱した

A 72-year-old female patient was diagnosed as having a tumor in her bladder at the department of obstetrics and gynecology. Transurethral resection of bladder tumor was performed in November, 2002. Pathology showed transitional cell carcinoma (TCC), G2>G3, pT1. Chemotherapy consisting of methotrexate, adriamycin and cisplatin and bladder instillation of Bacillus Calmette-Guerin (BCG) was performed. Re-biopsy revealed transitional cell carcinoma, G2, carcinoma in situ of the bladder and she received radical cystectomy with ureterocutaneostomy in June, 2003. After the cystectomy, the left ureter showed signs of cancer so BCG was administered through the left ureterocutaneostomy. During the second instillation, she had a high temperature and also exhibited signs of chills with frequent shivering followed by dyspnea, severe hypotension and tachycardia. We started the patient on dopamine and norepinephrine drips to maintain blood pressure and then started isoniazide and meropenem for presumed septic shock. The next day, the patient continued to be febrile and her condition deteriorated. After she was given endotoxin absorption therapy, she regained normal blood pressure and her heart rate, but was still febrile. After 13 days, rifampicin, ethambutol, and pyrazinamide were administered and after 18 days predonisolone was begun. From that point the patient's general condition gradually improved.