Yamada Midori, Nakashima Kei, Ito Hiroyuki, Aoshima Masahiro
Department of General Medicine, Awa Regional Medical Center, 1155, Yamamoto, Tateyama-shi, Chiba, 294-0014, Japan.
Department of Pulmonology, Kameda Medical Center, 929 Higashi-cho, Kamogawa-shi, Chiba, 296-8602, Japan.
Respir Med Case Rep. 2019 Oct 16;28:100955. doi: 10.1016/j.rmcr.2019.100955. eCollection 2019.
Corticosteroid therapy may not be enough to control pneumonitis in some cases of severe drug-induced lung injury (DLI); however, an advanced treatment strategy for such cases is lacking. Here, we report the case of an 88-year-old man who presented with severe DLI, caused by Sai-rei-to. The patient visited our hospital complaining of progressive dyspnea. High-resolution computed tomography of the chest demonstrated bilateral patchy ground-glass opacities and infiltrative shadows. Nasal high-flow oxygen therapy was initiated because of severe hypoxemia. Bronchoalveolar lavage on admission revealed diffuse alveolar hemorrhage. Further, as the patient had started taking Sai-rei-to a month earlier, DLI caused by Sai-rei-to was the most likely diagnosis. Therefore, Sai-rei-to was stopped and steroid pulse therapy was initiated. However, he still required high-flow oxygen therapy. We considered an alternative diagnosis of Goodpasture syndrome or anti-neutrophil cytoplasmic antibody (ANCA) related vasculitis. We initiated the administration of cyclosporin A and therapeutic plasma exchange (TPE), but his respiratory condition did not improve satisfactorily. Therefore, we also initiated intravenous immunoglobulin (IVIG) therapy for the treatment of potential vasculitis. Subsequently, his respiratory status began to improve. Further, tests for anti-glomerular basement membrane antibody, myeloperoxidase-ANCA, and proteinase 3-ANCA revealed negative results. Drug-induced lymphocyte stimulation test performed six months after withdrawing methylprednisolone was positive for Sai-rei-to. Thus, the final diagnosis was DLI due to Sai-rei-to. Our findings demonstrate that in cases of severe acute respiratory failure due to DLI, the multi-modal therapy with plasma exchange and IVIG in addition to conventional treatment with prednisolone and immunosuppressant may be beneficial.
在某些严重药物性肺损伤（DLI）病例中，皮质类固醇疗法可能不足以控制肺炎；然而，针对此类病例缺乏先进的治疗策略。在此，我们报告一例88岁男性因柴苓汤导致严重DLI的病例。患者因进行性呼吸困难前来我院就诊。胸部高分辨率计算机断层扫描显示双侧斑片状磨玻璃影和浸润性阴影。由于严重低氧血症，开始进行鼻高流量氧疗。入院时支气管肺泡灌洗显示弥漫性肺泡出血。此外，由于患者一个月前开始服用柴苓汤，最可能的诊断是柴苓汤引起的DLI。因此，停用柴苓汤并开始使用类固醇冲击疗法。然而，他仍需要高流量氧疗。我们考虑了另一种诊断，即Goodpasture综合征或抗中性粒细胞胞浆抗体（ANCA）相关性血管炎。我们开始给予环孢素A和治疗性血浆置换（TPE），但他的呼吸状况并未得到令人满意的改善。因此，我们也开始静脉注射免疫球蛋白（IVIG）治疗潜在的血管炎。随后，他的呼吸状况开始改善。此外，抗肾小球基底膜抗体、髓过氧化物酶-ANCA和蛋白酶3-ANCA检测结果均为阴性。停用甲泼尼龙六个月后进行的药物诱导淋巴细胞刺激试验显示对柴苓汤呈阳性。因此，最终诊断为柴苓汤所致的DLI。我们的研究结果表明，在因DLI导致严重急性呼吸衰竭的病例中除了使用泼尼松龙和免疫抑制剂进行常规治疗外，采用血浆置换和IVIG的多模式治疗可能有益。
