Omura Harutaka, Kajiki Akira, Nagata Nobuhiko, Kitahara Yoshinari, Wakamatsu Kentarou, Minami Takahiro, Taguchi Kazuhito, Katahira Katsuyuki
Department of Respiratory Medicine, National Hospital Organization Omuta National Hospital.
Kekkaku. 2011 May;86(5):509-14.
Paradoxical reaction in tuberculosis treatment is not generally fatal. On rare occasion it can lead a patient with diminished lung function and poor general condition to death. A 60-year-old man with history of left upper lobe resection from tuberculosis was referred to our hospital due to the recurrence of tuberculosis. Sputum examination showed a positive smear with a Gaffky score of 10, and the chest X-ray and CT revealed pulmonary infiltrate with many cavities (bII2) on the whole left lung field. Anti-tuberculosis drugs (isoniazid, rifampicin, ethambutol and pyrazinamide) were administered, but his high fever persisted, and the infiltrate on the chest X-ray deteriorated. While the positive sputum smear persisted, the culture became negative after one month. The tuberculous bacilli were susceptible to all anti-tuberculosis drugs in vitro. Though we performed examinations and trial treatments for non-tuberculous conditions such as pneumonia and drug-induced pneumonia, the patient died after 6 months. A necropsy specimen taken from the worsening lesion (the right upper lobe) as shown on the chest X-ray revealed many epithelioid granulomas. The patient had malnutrition, diabetes, alcoholic hepatic disorder, and insanity. It is supposed that although antituberculosis drugs were effective, a large quantity of killed organisms was continuously excreted from many cavities in the left lung toward the right lung. Lesions in the right lung thus newly produced in this paradoxical reaction seemed to reduce the remaining lung function. In addition, poorly controlled diabetes caused deteriorated heart function. These multiple factors contributed to the poor prognosis of the patient and his ultimate death.
结核病治疗中的矛盾反应一般不会致命。极少数情况下，它可能导致肺功能减退和全身状况不佳的患者死亡。一名60岁有左上叶结核切除病史的男性因结核病复发被转诊至我院。痰检显示涂片阳性，加夫基评分10分，胸部X线和CT显示整个左肺野有许多空洞的肺部浸润（bII2）。给予抗结核药物（异烟肼、利福平、乙胺丁醇和吡嗪酰胺），但他持续高热，胸部X线显示的浸润情况恶化。虽然痰涂片持续阳性，但培养在1个月后转为阴性。结核杆菌在体外对所有抗结核药物敏感。尽管我们对非结核性疾病如肺炎和药物性肺炎进行了检查和试验性治疗，但患者在6个月后死亡。从胸部X线所示病情恶化的病灶（右上叶）获取的尸检标本显示有许多上皮样肉芽肿。该患者有营养不良、糖尿病、酒精性肝病和精神错乱。据推测，尽管抗结核药物有效，但大量被杀死的病菌不断从左肺的许多空洞排向右肺。这种矛盾反应中新产生的右肺病灶似乎降低了剩余的肺功能。此外，控制不佳的糖尿病导致心脏功能恶化。这些多种因素导致了患者预后不良并最终死亡。
