Ohara Maiko, Tomoda Fumihiro, Nakagawa Taizo, Masutani Toshitaka, Liu Hexing, Ichikawa Kumi, Hirose Masayo, Koike Tsutomu, Kagitani Satoshi, Inoue Hiroshi
The Second Department of Internal Medicine, University of Toyama, Toyama, Japan.
Nihon Jinzo Gakkai Shi. 2010;52(8):1037-42.
A 55-year-old man was admitted to our hospital because of arthralgia, purpura, abdominal pain, melena and leg edema. Laboratory findings showed an increased serum creatinine level (2.4 mg/dL), hematuria and massive proteinuria (10.7 g/day). Renal biopsy revealed diffuse endocapillary proliferation and focal mesangial proliferation with IgA deposition predominantly in the glomerular capillary walls. Based on these findings, he was diagnosed as having Henoch-Schönlein purpura nephritis and steroid therapy was started. Following steroid therapy, his nephrotic state remained unchanged, although his renal function improved concomitantly with the disappearance of arthralgia, purpura and abdominal symptoms. Therefore, cyclosporine was added to the steroid therapy to enhance immunosuppression. However, melena recurred and anemia progressed. Endoscopy revealed multiple ulcers in the duodenum and jejunum, and clipping was performed at some bleeding sites. However, he died of hemorrhagic shock. The autopsy revealed that hemorrhagic lesions having cytomegalovirus infection spread widely in the stomach, duodenum and jejunum. Recurrence of gastrointestinal bleeding during the treatment of Henoch-Schönlein purpura nephritis is usually due to severe vasculitis or steroid ulcer. However, in patients receiving strong immunosuppressive therapy, cytomegalovirus infection needs to be considered as cause of gastrointestinal bleeding.
一名55岁男性因关节痛、紫癜、腹痛、黑便和腿部水肿入院。实验室检查结果显示血清肌酐水平升高（2.4mg/dL）、血尿和大量蛋白尿（10.7g/天）。肾活检显示弥漫性毛细血管内增生和局灶性系膜增生，IgA主要沉积于肾小球毛细血管壁。基于这些发现，他被诊断为过敏性紫癜性肾炎，并开始使用类固醇治疗。类固醇治疗后，尽管随着关节痛、紫癜和腹部症状的消失肾功能有所改善，但他的肾病状态仍未改变。因此，在类固醇治疗中加用环孢素以增强免疫抑制作用。然而，黑便复发且贫血加重。内镜检查发现十二指肠和空肠有多处溃疡，并在一些出血部位进行了钳夹止血。然而，他死于失血性休克。尸检显示，感染巨细胞病毒的出血性病变广泛蔓延至胃、十二指肠和空肠。过敏性紫癜性肾炎治疗期间胃肠道出血的复发通常是由于严重血管炎或类固醇溃疡。然而，在接受强效免疫抑制治疗的患者中，需要考虑巨细胞病毒感染是胃肠道出血的原因。
