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肝膿瘍

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肝膿瘍

  1. 1. 感染性肝膿瘍 Pyogenic Liver Abscess (from UpToDate 15.3)
  2. 2. 疫学  頻度  18-20case/100,000入院 2.3case/100,000人  死亡率は12%  原因菌ではK. pneumoniaeが最多  右葉に多い(感染の機序に由来する)  Risk factor  男性 vs 女性 (3.3 vs 1.3/100,000)  高齢者, 糖尿病  地域性: 台湾では446/100,000入院, アジアで多い
  3. 3. 感染経路  経胆道感染が40-60%を占める  悪性腫瘍による胆道閉塞が最も多い  血行播種 → 稀  Streptcoccal, Staphが検出された場合は 遠位臓器からの散布を考慮する必要がある  腹膜炎からの直接播種  外傷や, 外科手術による感染も  肝膿瘍の診断がつけば, 感染経路を探すこともわすれないこと!
  4. 4. 肝膿瘍はHCCの初症状かも?  台湾における1997-2008年に報告された肝膿瘍32454例の解析  平均年齢61歳. 18-106歳まで分布. 男性例が61.3% 糖尿病41.3%, 肝硬変7.2%, 胆石症23.7%, 慢性肺疾患6.9%  HCCの初発症状として肝膿瘍を認めた例が2.15%あり, 特に>65y, HBV, HCV陽性, 肝硬変(+)群ではhigh risk.  60d死亡率はHCC群で14.5%, 非HCC群で8.1%と予後にも関わる. 治療方針にも関わるため, HCCの関与の有無を評価するのは大事. The American Journal of Medicine (2011) 124, 1158-1164
  5. 5. genic liver abscess as the initial manifestation of underlying hepatocellular carcinoma has been reported only in a small case series from east Asia.12-14 To our knowledge, this is the first attempt to investigate the frequency of, risk factors for, cellular carcinoma was already present in our patients at the time pyogenic liver abscess was diagnosed. We found that liver cirrhosis, hepatitis B virus infection, hepatitis virus C virus infection, and advanced age were independent risk Characteristics Pyogenic Liver Abscess as the Initial Manifestation of Underlying Hepatocellular Carcinoma (n ϭ 698) Pyogenic Liver Abscess without Hepatocellular Carcinoma (n ϭ 31,756) P ValueNumber % Number % Sex Male 463 66.3 19,429 61.2 .006 Female 235 33.7 12,327 38.8 Age, years Ͻ.001 Ͻ65 319 45.7 17,292 54.5 Ն65 379 54.3 14,464 45.5 Comorbidity Diabetes mellitus 184 26.4 13,231 41.7 Ͻ.001 Chronic renal failure 54 7.7 2554 8.0 .826 Autoimmune diseases 5 0.7 174 0.5 .441 Chronic pulmonary disease 69 9.9 2173 6.8 .002 Liver cirrhosis 247 35.4 2085 6.6 Ͻ.001 Cholelithiasis 172 24.6 7522 23.7 .561 Hepatitis B virus infection 136 19.5 1106 3.5 Ͻ.001 Hepatitis C virus infection 100 14.3 647 2.0 Ͻ.001 Septic metastasis* 1 0.1 606 1.9 Ͻ.001 Management Abscess drainage 128 18.3 9972 31.4 Ͻ.001 Surgical intervention 193 27.7 4497 14.2 Ͻ.001 60-day mortality 101 14.5 2574 8.1 Ͻ.001 *Including endophthalmitis or meningitis. HCCの初症状としての肝膿瘍 vs HCCに関係しない肝膿瘍 DMが無く, 肝硬変, HBV, HCV(+)の患者での肝膿瘍ではHCCの関与を疑う
  6. 6.  大腸癌関連の肝膿瘍96例の報告例の解析.  報告例の大半が東アジアから. 特に日本からは40例と多い. 中国 26例, 韓国 8例.  報告例の平均年齢 64.4±10.1y 男女比は1.5:1と男性で多い. 大腸癌→肝膿瘍のパターンも増加中 World J Gastroenterol 2012 June 21; 18(23): 2948-2955 Country/region No. of cases No. of articles Eastern Asia Japan 40 36[6-10]1 China 26 6[4,5,11-14] Korea 8 1[15] Singapore 3 1[16] Middle East and Europe Israel 3 3[17-19] Italy 2 2[20,21] Spain 2 2[22,23] Portugal 1 1[24] France 1 1[25] United Kingdom 1 1[26] North and Central America United States 7 7[2,27-32] Canada 1 1[33] Netherlands Antilles 1 1[34] Total 96 63 Table 1 Documented cases collected from the international literature Qu K et al. Liver abscess complicated with colorectal can o. of cases No. of articles 40 36[6-10]1 26 6[4,5,11-14] 8 1[15] 3 1[16] 3 3[17-19] 2 2[20,21] 2 2[22,23] 1 1[24] 1 1[25] 1 1[26] 7 7[2,27-32] 1 1[33] 1 1[34] 96 63 ted from the international cle reference were included[8] . Pathogens Eastern Asia Non-Eastern Asia Total (n = 49) (n = 9) (n = 58) Bacteria Gram negative bacteria Klebsiella pneumoniae 28 (57.14) 1 (11.1) 29 (50.0) Fusobacterium species 4 (8.16) 0 4 (6.90) Bacteroides species 2 (4.08) 1 (11.1) 3 (5.17) Escherichia coli 0 1 (11.1) 1 (1.72) Pseudomonas aeruginosa 1 (2.04) 0 1 (1.72) Gram positive bacteria Streptococcus species 1 (2.04) 3 (33.3) 4 (6.90) Enterococcus faecium 2 (4.08) 0 2 (3.44) Polymicrobial 0 2 (22.2)1 2 (3.44) Amoebae 2 (4.08) 0 2 (3.44) Negative 9 (18.37) 1 (11.1) 10 (17.24) Table 2 Constituent ratio of pus bacterial cultures n (%) 1 Pus cultures showed mixed infection in two patients: E. corrodens, Candida albicans and Candida glabrata; Peptostreptococcus anaerobius, Bacteroides mela- ninogenicus and Peptostreptococcus spp. y/region ountry/region 990 1991-2000 2001-2011 (yr) Eastern Asian country/region Non-Eastern Asian country/region 41-50 51-60 61-70 71-80 > 80 Age (yr) No.ofcases 30 20 10 0 Figure 2 Age distribution of reported cases in different countries/regions. plicated with colorectal cancers
  7. 7.  原因菌;  アジアでは, GNRが多く, 特にKlebsiella pneumoniae.  海外はGP, GNが同等程度 No. of cases No. of articles 40 36[6-10]1 26 6[4,5,11-14] 8 1[15] 3 1[16] urope 3 3[17-19] 2 2[20,21] 2 2[22,23] 1 1[24] 1 1[25] 1 1[26] America 7 7[2,27-32] 1 1[33] lles 1 1[34] 96 63 mented cases collected from the international Pathogens Eastern Asia Non-Eastern Asia Total (n = 49) (n = 9) (n = 58) Bacteria Gram negative bacteria Klebsiella pneumoniae 28 (57.14) 1 (11.1) 29 (50.0) Fusobacterium species 4 (8.16) 0 4 (6.90) Bacteroides species 2 (4.08) 1 (11.1) 3 (5.17) Escherichia coli 0 1 (11.1) 1 (1.72) Pseudomonas aeruginosa 1 (2.04) 0 1 (1.72) Gram positive bacteria Streptococcus species 1 (2.04) 3 (33.3) 4 (6.90) Enterococcus faecium 2 (4.08) 0 2 (3.44) Polymicrobial 0 2 (22.2)1 2 (3.44) Amoebae 2 (4.08) 0 2 (3.44) Negative 9 (18.37) 1 (11.1) 10 (17.24) Table 2 Constituent ratio of pus bacterial cultures n (%) 1 Pus cultures showed mixed infection in two patients: E. corrodens, Candida albicans and Candida glabrata; Peptostreptococcus anaerobius, Bacteroides mela- ninogenicus and Peptostreptococcus spp. ver abscess complicated with colorectal cancers World J Gastroenterol 2012 June 21; 18(23): 2948-2955
  8. 8.  肝膿瘍の部位は右葉が2/3.  両側性のこともある.  大腸癌の部位は,  直腸, S状結腸が最多.  ただし, 何処でもありえる. Liver Stomach Abscess locatioin 7.6% Transverse colon 18.2% 6.0% Tumor 40.9% 27.3% Sigmoid colon Right lobe 66.7% Both lobes 12.1% Left lobe 18.2% Rectum Descendingcolon Ascendingcolon Figure 4 Distribution of colorectal cancer and liver abscesses. World J Gastroenterol 2012 June 21; 18(23): 2948-2955 GNRでも遠隔転移の可能性がある また, 肝膿瘍は肝癌, 大腸癌に 由来するものの可能性もあり, リスクがある場合はチェックが必要.
  9. 9. 起因菌  膿瘍の培養陽性は56%  肝膿瘍の大半がPolymicrobial(嫌気性菌を含む)  S. aureus, S. pyogenes → TAEに合併する肝膿瘍の60%  Actinomyces, Yersinia  Candida → 化学療法, 好中球減少症で注意  S. milleri → 他の部位に感染が播種していることが多い  結核性は少ないが, 考慮しておかなければならない  6ヶ月以内の旅行歴ではアメーバ性肝膿瘍も (圧痛の伴う, 充実性の膿瘍)
  10. 10. 起因菌(K. P.)  K. pneumoniaeが最も多い起因菌  原因が判明した肝膿瘍の43%[23-54]を占める  特にアジアでは多い, 台湾の肝膿瘍の69%  市中感染症としての感染もある  Risk factor; DM, アルコール依存, 悪性腫瘍 COPD, ステロイド使用患者  眼内炎, 髄膜炎, 椎体炎, 各部膿瘍の合併もある  進入経路が不明な場合 → K. P.単独感染が多い  肝胆道系感染が誘因の場合 → Polymicrobialが多い  K.P.では単独感染が多い(65-68%)
  11. 11. K. pneumoniae  毒性に地域差がある  市中感染の肝膿瘍, 髄膜炎, 眼内炎はAsia, 南アフリカのみ  Asia, 南アフリカのK.P.では  Mucoid Phenotype; 100% vs 2% rmpA(+); 86% vs 7% K1, K2 capsular serotype, magAなども有意に多く認める 肝膿瘍を来たしたK.P.の83%がmagA(+)  膿瘍は実質, 膿瘍の混在型 (多房性をとる)  K.P.の膿瘍形成が 緩徐であるため, 入り混じる 補足
  12. 12. ムコイドタイプのK.P.  Capsular serotype K1, K2がムコイドK.P.に関与.  遺伝子検査は研究室レベルでないと不可能だが, ムコイドタイプのK pneumoniaeの検出にはString signで分かる.  コロニーをすくって, 粘液糸(>5mm)を認めれば ムコイドタイプである可能性.  その場合, 眼内炎やCNS播種のリスクが高いため, 眼窩診察が必要となる. Clinical Infectious Diseases 2012;54(2):303–4 abscess. However, Echinococcus granulosis is not endemic in the Philippines [1], and radiographic features considered pathogno- monic for hydatid cysts (such as the presence of a laminar layer or of daughter cysts that contain fluid of lower density than the surrounding mother cyst fluid [2]) were absent. In this case, epidemiologic, historic, and imaging characteristics (seeFigure 1) pointed toward a diagnosis of pyogenic liver abscess, while growth of bacterial colonies with features characteristic of K. pneumoniae on blood agar (see Figure 2) confirmed the diagnosis. In recent series, pyogenic liver abscess has been incre- asingly common in patients of Asian descent [3, 4]. A previous history of biliary disease, as in this case, is an important risk factor for pyogenic liver abscess [4]. Further, the most common radiographic finding in amoebic liver abscess (ALA) is a single, common finding is that of a single, right-sided lesion [3]. Over the past few decades, a clinically distinct syndrome o community-acquired K. pneumoniae liver abscess (KLA) has bee described by researchers in Taiwan and other areas. This syn drome affects relatively healthy hosts, has been variably associate with the presence of diabetes mellitus as an underlying risk facto and causes a high rate of metastatic spread. K. pneumoniae isolat from these patients have reliably been linked to the hyperprodu tion of capsular, or slime, polysaccharide (ie, hypermucoviscosity which forms a ‘‘string’’ when the colony is touched by a loop (se Figure 2). The pathogenesis of this syndrome is under study, bu the presence of capsular serotype K1, and to a lesser extent K appears to play a role in the virulence of the organism [7, 8]. Management of pyogenic liver abscess includes effective ant microbial therapy, in combination with surgical or percutaneou drainage in most cases. Curative medical management alone possible, but is associated with a higher risk of complications suc asabscessruptureorrelapse.Bacteremiaisverycommonincases KLA, and metastatic or extrahepatic abscesses have been reporte
  13. 13.  Klebsiella pneumoniaeは莢膜があるタイプは 貪食されにくく, 毒性が強い.  他に粘性のK.P.も同様に貪食されにくく, 毒性が強くなる.  粘性(ムコイドタイプ)のK.P.の代表例がSubtype K1,K2.  ムコイドにはrmpAやmagAなどの遺伝子変異が関連している.  逆にrmpAやmagAが欠損しているK1,K2 typeでは粘性は認められない. LancetInfectDis2012; 12: 881–87
  14. 14.  Subtypeと毒性の関係  magA, rmpAは 肝膿瘍に関連する rmpA Aerobactin Resistance Virulence* Phagocytic Serum K118 + + + + +++ K118 + + + − V(+++,+) K118 + + − − + K118 + − + + + K118 + − + − + K142 + + ND ND V(+++,+) K142 − − ND ND − K2* + + + + +++ K2* + + + − V(+++,+) K2* + + − + V(+++,+) K2* + − + − + K142 + + ND ND V(+++,+) K142 − − ND ND V(+,−) Non K1 or K242 + + ND ND V(+++,+) Non K1 or K242 − − ND ND − +=virulent strains with a 50% lethal dose (LD50) of ≥1×10³ colony-forming units (CFU) and >1×10⁶ CFU are less likely to induce complications in mice. +++=hypervirulent strains with an LD50 of less than 1×10³ CFU are more likely to induce complications in mice. −=non-virulent strains with an LD50 of 1×10⁶ CFU of greater (do not cause complications). ND=no data. V=variable. *Chang F-Y, unpublished data. Table 2: Microbiological features of Klebsiella pneumoniae associated with virulence, by serotypeLancetInfectDis2012; 12: 881–87
  15. 15.  ムコイドタイプのK.P. (K1,K2)   Wild typeでは粘糸を認めるが magA, rfbPm rmpA欠損例では 粘糸が認められない. (Δ; deletion) function is restricted to the capsular gene cluster of serotype K1 only.48,49 Silencing of genes surrounding magA (figure) in the same cluster of genes needed for capsular polysaccharide synthesis resulted in hypermucoviscosity and virulence.23 In 2006, rmpA was proposed as a virulent factor in addition to magA and capsular serotypes K1/K2.50 rmpA is not an independent factor contributing to liver abscess but aids capsule synthesis.7 One report showed that all rmpA Aerobactin Resistance Virulence* Phagocytic Serum K118 + + + + +++ K118 + + + − V(+++,+) K118 + + − − + K118 + − + + + K118 + − + − + K142 + + ND ND V(+++,+) K142 − − ND ND − K2* + + + + +++ K2* + + + − V(+++,+) K2* + + − + V(+++,+) K2* + − + − + K142 + + ND ND V(+++,+) K142 − − ND ND V(+,−) Non K1 or K242 + + ND ND V(+++,+) Non K1 or K242 − − ND ND − +=virulent strains with a 50% lethal dose (LD50) of ≥1×10³ colony-forming units (CFU) and >1×10⁶ CFU are less likely to induce complications in mice. +++=hypervirulent strains with an LD50 of less than 1×10³ CFU are more likely to induce complications in mice. −=non-virulent strains with an LD50 of 1×10⁶ CFU of greater (do not cause complications). ND=no data. V=variable. *Chang F-Y, unpublished data. Table 2: Microbiological features of Klebsiella pneumoniae associated with virulence, by serotype Wild-type Δwzy(magA) ΔrfbP ΔrmpA Serotype K1 Serotype K2 LancetInfectDis2012; 12: 881–87
  16. 16. K. pneumoniae  播種は11.9-13%で認められる  他の原因菌よりも多い (14.6 vs 3.8%)  髄膜炎, 眼内炎, 椎体炎, 椎間板炎, 壊死性筋膜炎 脾膿瘍, Septic emboli, 肺膿瘍, 腸腰筋膿瘍, 頚部膿瘍 骨髄炎など  K1,K2(+) K.P.では眼内炎合併頻度が多い(10-15%) 補足
  17. 17.  K.P.肝膿瘍例 USA (n=3821,24 ) South Korea (n=32111,12 ) Taiwan (n=51225–28 ) Mean age (years) 53·6 59·9 57·4 Men 68% (26/38) 42% (136/321) 63% (321/512) Ethnic origin Asian 50% (16/32)* 100% (58/58)† 100% (512/512) Hispanic 25% (8/32)* ·· ·· Black 13% (4/32)* ·· ·· White 9% (3/32)* ·· ·· Underlying disorder Diabetes mellitus 29% (11/38) 38% (122/321) 63% (323/512) Hepatobiliary disease 18% (7/38) 20% (64/321) 25% (127/512) Cancer 3% (1/38) 6% (20/321) 7% (38/512) Alcoholism 0 16% (50/321) 8% (40/512) Chronic renal failure 0 <1% (1/321) 3% (16/512) Bacteraemia 74% (28/38) 48% (153/321) 61% (312/512) Single abscess 74% (28/38) 62% (198/321) 77% (392/512) Multiple abscesses 26% (10/38) 38% (123/321) 23% (120/512) Location of abscess Right hepatic lobe 65% (24/37)‡ 64% (37/58)§ 65% (333/512) Left hepatic lobe 24% (9/37)‡ 24% (14/58)§ 25% (129/512) Both lobes 11% (4/37)‡ 12% (7/58)§ 10% (50/512) Metastatic infection 24% (9/38) 8% (26/321) 15% (62/428)¶ Lung 16% (6/38) 3% (2/58)§ 4% (16/428)¶ Eye 11% (4/38) ··§ 4% (18/428)¶ CNS 8% (3/38) 2% (1/58)§ 5% (21/428)¶ Muscular and skeletal system 3% (1/38) ··§ 2% (9/428)¶ Urinary system 3% (1/38) ··§ <1% (1/428)¶ Mortality 8% (3/38) 4% (10/263)|| 6% (30/512)LancetInfectDis2012; 12: 881–87
  18. 18. K. Pneumoniae菌血症  E. coliに次いで2番目に多いGNR菌血症の原因  原発巣 HCA; Healthcare associated  Asiaでは毒性が強く, 肝膿瘍の原因となるばかりではなく, 世界的にESBLが増加し, 問題に. Am J Med 2009;122:866-73 Focus Total 院内感染 HCA 市中感染 Primary 30% 52% 27% 11% 胆道系 19% 7.5% 19% 34% 泌尿生殖器 25% 12% 30% 32% 腹腔内感染 10% 11% 9.4% 9.6% 膵炎 1.7% 2.3% 0.8% 2.4% 肺炎 8% 11% 9.8% 4.8% 皮膚, 軟部組織 1% 1.7% 1.2% 0 肝膿瘍 2.3% 1.1% 1.2% 5.4% CNS <1% 0.6% 0 1.2% 骨 <1% 0 0.4% 0
  19. 19. K. Pneumoniae菌血症  640名のK. pneumoniae菌血症を解析(2000-2007, @ Canada)  平均年齢は68.9yr[53.0-79.3], 高齢者ほどHigh Riskとなる  男性で多い, RR 1.4[1.2-1.6]  院内感染が27%, Healthcare associatedが43%, 市中感染が30%  Risk Factorは臓器移植, 慢性肝障害, 透析, 悪性腫瘍  K. pneumoniae菌血症の頻度は7.1/100,000/yr  E. coli(30/100,000/yr), S. aureus(28/100,000/yr)よりも少なく,  Pseudomonas aeruginosa(6.4/100,000/yr), Strep. A,B,C,G(4.3, 3.1, 0.41, 1.83/100,000/yr)よりも多い. Am J Med 2009;122:866-73
  20. 20. 臨床症状  発熱 90%  腹痛, 圧痛 55-90%  悪寒 38-49%  食欲不振 38%  体重減少 25-43%  嘔気, 嘔吐 28-43%  怠感, 衰弱 30% → 特異的な症状は無し (胆嚢炎と似ている) 肝腫大, 右季肋部痛は50% → 痛みがなくても否定は困難 不明熱の原因としても重要
  21. 21. N.Y.の79名の解析  平均年齢は56.4y[25-90]  胆道系疾患は43%で認められた. ALP上昇は66.7%, AST上昇は46.2%, ALT上昇は53.8%で認められた. LDH上昇は17.2%のみ.  症状頻度  発熱は90%. RUQ痛は70%. Clinical Infectious Diseases 2004;39:1654–9
  22. 22.  原因菌頻度  最も多いのはKlebsiella spp. 特にアジア人で多い.  単一菌のみ検出は44%. 検出できなかったのが31% それ以外の25%は 複数菌による感染症. Clinical Infectious Diseases 2004;39:1654–9 Figure 3. Identity of organisms recovered from patients with pyogenic liver abscesses. only bacterial isolate. The number of bacterial species isolated from the abscess cavity for each case is shown in figure 2. Most often, only a single organism was identified (44.2% of cases). The species of bacteria that were isolated are summarized in figure 3. K. pneumoniae was the species most commonly iso- lated and was found in 41% of the 54 cases in which an or- ganism was recovered. E. coli and Enterococcus species were tied as the second most commonly isolated organisms (11 cases each). Klebsiella isolates were more common among Asian pa- ganism was recovered. E. coli and Enterococcus species were tied s the second most commonly isolated organisms (11 cases ach). Klebsiella isolates were more common among Asian pa- ients than other patients, and they were only isolated from Asian and Hispanic patients (figure 4). Eighteen (50%) of 36 Asian patients had K. pneumoniae isolated, in contrast with 6 27%) of 22 non-Asian patients, a difference that was not sta- istically significant ( ).P p .075 In the 23 cases in which K. pneumoniae was recovered, it was most often the only pathogen. Only 5 of the 23 infections were polymicrobial. K. pneumoniae was recovered in 22 (46.8%) of 47 cases in which there was no extrahepatic intra-abdominal nfection, but it was recovered in only 1 of 11 cases in which uch an infection was present. The percentage of K. pneumoniae solates recovered was similar in cases from Bellevue Hospital nd NYU Downtown Hospital (42.4% and 40.0%, respectively). Twenty-one of the 23 K. pneumoniae isolates were tested for ntimicrobial susceptibility. Almost all of the isolates were highly susceptible, with only 3 isolates showing resistance to ny drug tested other than ampicillin. Only 1 isolate was an xtended-spectrum b-lactamase (ESBL) producer. There was no significant difference in the number of febrile days or days hospitalized between patients with and patients without K. pneumoniae isolates, nor was there any significant difference between K. pneumoniae and non–K. pneumoniae ases in terms of the initial laboratory parameters. Only 1 pa- ient was noted to have a Klebsiella species isolated other than K. pneumoniae (Klebsiella oxytoca), but it was found in con- unction with K. pneumoniae. abdominal ultrasound examination. The most common primary treatment modality was percu- taneous drainage, which was done in 44 patients (55.7%). Twenty patients (25.3%) were treated surgically, and 14 (17.7%) were treated medically. Treatment patterns differed significantly be- tween the 2 hospitals. At Bellevue Hospital, 67.4% of the patients were treated primarily with percutaneous drainage, 19.6% re- ceived medical management, and 13.0% received surgical man- agement. At NYU Downtown Hospital, 43.8% were treated surgically, 40.6% were treated with percutaneous drainage, and 15.6% received medical management ( ; ;2 x p 9.50 df p 2 P p ). This difference was attributed to the lack of on-site in-.009 terventional radiology at NYU Downtown Hospital. ess. or- en- on es- xcel 11 s of x2 bles YU age ale. ite, pa- re- wn nts ion ere The ue, rast was present in 32 (43%) of 74 patients who had data recorded for all 3 findings, and 86% had у2 of these symptoms and signs on initial evaluation. Sixty (77%) of 78 evaluable abscesses were solitary. Fifty- four (70.5%) were right sided, 11 (14.1%) were left sided, and 4 (5.1%) were bilateral. In 9 patients, the location of the abscess was not documented. The most common underlying or concomitant conditions were biliary disease (in 34 [43%] of the patients), hypertension (14 [17.7%]), intra-abdominal infection (14 [17.7%]), and di- abetes (12 [15.2%]). Other underlying diseases included ma- lignancy (12.7%), cardiovascular disease (12.7%), alcohol abuse (2.5%), and cirrhosis, diverticulitis, and inflammatory disease (1.3% each). Fifty-four patients had у1 organism recovered from the ab- scess. Eighteen (33.3%) of the infections were polymicrobial; 6 of these included anaerobes. In 2 cases, anerobes were the byguestonJuly25,2011cid.oxfordjournals.orgDownloadedfrom
  23. 23. 検査所見  特異的な血液検査は無し  ALP上昇が67-90%に認められる  Bil, ALT, ASTは50%程度  画像所見  右側の胸水, 右肺底部浸潤影  エコー, 造影CT, MRIがDiagnostic  確定診断は 刺し膿瘍の検出
  24. 24. 治療 抗生剤  抗生剤 + ドレナージ が原則  アメーバ膿瘍の場合はドレナージ必要なし  抗生剤; Empiric TherapyのRCTは未だない  起因菌をカバーする抗生剤を用いる  AM-SB(3g q6hr), PIPC/TZ(4.5g q6hr)  Metro(500mg IV q8hr) + 3’ Ceph(CTRX 1g qd)  カルバペネム  Metro(500mg IV q8hr) + FQ IV(Cip400mg q12hr) (Levo500mg qd)  投与期間は決まっていない(4-6W) 画像所見に応じて中止時期を決める
  25. 25. 治療 ドレナージ  ドレナージは3方法【経皮的】,【外科的】,【ERCP】  経皮的が最も簡便  カテーテル留置とAspirationでは同等の効果 (成功率97%, 数回 刺する必要があるのが難点)  【経皮的】vs【外科的ドレナージ】 → 治療成功率は外科的ドレナージで良好 入院期間も短縮, 合併症は双方同程度  多胞性, 多発性, 高粘稠度の膿瘍, 肝胆道系に異常が ある場合は外科的ドレナージが有効
  26. 26. 治療 ドレナージ  ドレナージの(お)ススメ (from UpToDate)  原則; 経皮的ドレナージ + カテーテル留置  膿瘍 < 3cmならばAspirationでOK  経皮的ドレナージ失敗リスクが高い場合, 肝胆道系に基礎疾患がある場合, 多胞性, 巨大膿瘍の場合は外科的ドレナージ
  27. 27. 治療・その他  眼内炎治療(from UpToDate)  内因性眼内炎は眼科Emergency!  失明する可能性が高い(治療をしても10%)  抗生剤の水晶体内注射; Ceftazidime 2.25mg (原因菌感受性の高いもの)  Dexamethasone 0.4mgの水晶体投与 (Controversial)  抗生剤DIV投与(肝膿瘍に準じる) *Empiric; Vancomycin 1mg, Amikacin 0.4mg, Ceftazidime 2.25mgの水晶体内投与 *点眼抗生剤 レボフロキサシン, オキシフロキサシンの眼内透過性は 微々たるもので, MIC(50, 90)に達することはない (Graefes Arch Clin Exp Ophthalmol. 2006;244:1633-7.)

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