Nojima Daisuke, Ozaki Shinji, Fujii Yasuhiro, Wada Sae, Ono Katsuichiro, Fujimoto Nobukazu, Gemba Kenichi, Kishimoto Takumi
Department of Respiratory Medicine, Okayama Rosai Hospital.
Nihon Kokyuki Gakkai Zasshi. 2009 Mar;47(3):195-9.
An 87-year-old woman was admitted because of high fever, progressive dyspnea and abnormal shadows on chest roentgenogram. Laboratory investigation on admission demonstrated a normal white cell count with neutrophilia (4000/microl, 90.5% neutrophils), an erythrocyte sedimentation rate of 10 mm/h and C-reactive protein value of 9.0mg/dl. Roentgenogram and computed tomographic scan of the chest shows bilateral infiltration and diffuse ground glass opacity, indicating acute respiratory distress syndrome (ARDS), but disseminated nodules, indicating miliary tuberculosis, were not found. Blood gas analysis demonstrated severe hypoxemia (PaO2 43.2Torr with 6L/ min oxygen). Based on the diagnosis of acute pneumonia and ARDS, intravenous administration of sivelestat sodium hydrate (100 mg/day), and continuous infusion of hydrocortisone (200 mg/day) were started. PaO2/FiO2 ratio improved but X-ray findings showed no improvement and a blood test revealed pancytopenia. Bone marrow biopsy revealed necrotizing epithelioid granuloma and acid-fast bacilli. A polymerase chain reaction (PCR) test detected Mycobacterium tuberculosis. Mycobacterium tuberculosis was also detected in sputum and urine. Therefore, we diagnosed miliary tuberculosis and transferred the patient to an infectious disease hospital. Miliary tuberculosis complicated with ARDS is relatively rare and the prognosis is extremely poor. Miliary tuberculosis should be kept in mind as a cause of ARDS.
一名87岁女性因高热、进行性呼吸困难及胸部X线片出现异常阴影入院。入院时实验室检查显示白细胞计数正常但中性粒细胞增多（4000/微升，中性粒细胞90.5%），红细胞沉降率为10毫米/小时，C反应蛋白值为9.0毫克/分升。胸部X线片和计算机断层扫描显示双侧浸润及弥漫性磨玻璃样混浊，提示急性呼吸窘迫综合征（ARDS），但未发现提示粟粒性肺结核的播散性结节。血气分析显示严重低氧血症（吸氧6升/分钟时PaO2为43.2托）。基于急性肺炎和ARDS的诊断，开始静脉注射水合西维来司他钠（100毫克/天），并持续输注氢化可的松（200毫克/天）。PaO2/FiO2比值有所改善，但X线表现无改善，血液检查显示全血细胞减少。骨髓活检发现坏死性上皮样肉芽肿和抗酸杆菌。聚合酶链反应（PCR）检测发现结核分枝杆菌。痰液和尿液中也检测到结核分枝杆菌。因此，我们诊断为粟粒性肺结核，并将患者转至传染病医院。粟粒性肺结核合并ARDS相对罕见，预后极差。粟粒性肺结核应作为ARDS的病因之一予以考虑。
