保存的治療により軽快した気腫性腎盂腎炎の1例 ―保存的治療の適応について―

Abstract

症例:51歳女.発熱および左側腹部痛が出現し, 画像上左腎部の気腫性変化を認めたため精査となった.血液検査, 尿検査, 腹部単純写真およびCT検査より左気腫性腎盂腎炎に伴う敗血症, DICと診断した.敗血症, DICに対する治療と同時にパニペネムを開始した.発熱およびCRPはいったんは改善したが再発, ピペラシリンに変更したがCRP再上昇を認め, イミペネム・シラスタチンに変更したところ両者とも改善した.高血糖が認められたがインシュリン, クリベンクラミドでコントロール可能となった.白血球増多, 微熱を残して退院した.腹部CT上の気腫像は退院後3ヵ月で著明に限局化し, 4ヵ月でほとんど消失した.微熱は3ヵ月で消失, 白血球増多は4ヵ月で正常化した.DMSAシンチでは患側腎に約30%のRI取込を認め, 腎機能残存が確認された

A 51-year-old female patient was hospitalized in our department with high fever and left flank pain. Laboratory examination showed leukocytosis, increase of C-reactive protein (CRP), hyperglycemia and renal insufficiency. Enterobacter aerogenes grew out of the cultured urine. The radiograph and computerized tomographic (CT) scan revealed streaky gas in the destroyed left renal parenchyma with perirenal gas. She was diagnosed with left emphysematous pyelonephritis. Antibiotics therapy, treatment for sepsis and disseminated intravesicular coagulation was initiated resulting in mitigation of inflammation. High blood glucose initially required insulin therapy, but finally returned to normal levels through administration of oral antidiabetics. Although leukocytosis and low grade fever continued, the patient was discharged on day 53 with a negative CRP. CT scan indicated that the emphysematous change was localized after three months and almost resolved after four months. Renal scintigram indicated the residual function of the affected kidney. Because of the possibility of residual renal function and the cure by conservative therapy alone, the conservative therapy is preferred when the initial treatment is effective.