妊娠の経過中に発症し急性呼吸不全症状を呈した粟粒結核症の1例

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A case of miliary tuberculosis associated with acute respiratory failure during pregnancy was reported. A 39-year-old, 29-week pregnant woman was admitted to our hospital with complaints of nonproductive cough and fever on June 12. On admission, her temperature was 38.2°C pulse rate was 90/min., and blood pressure was 120/76mmHg. Physical examination revealed moist rales at right lung basis. Chest X-ray showed small nodular infiltrates in right lower lung field. Laboratory data revealed positive CRP, accelerated ESR and increased level of α2-globulin. The number of T-cells was markedly decreased (14/mm3). The PPD skin test was negative, and the sputum smears for acid-fast bacilli were negative. Suspected of bacterial or viral pneumonia, the patient was treated with antibiotics (CPM, EM and CAZ), which had no effects for her. On June 16, the Chest X-ray showed infiltrates throughout bilateral lung fields, and the patient became increasingly dyspneic. On June 18, the results of arterial blood gas, analysis under room air were: PaO2 26.7 Torr, PaCO2 29.0 Torr, pH7.505. Because of severe hypoxemia, she was intubated and placed on a volume-cycled respirator. Hydrocortisone (1000mg, daily) was added totreatment because ARDS was suspected. Since the smears of tracheobronchial secretions showed acid-fast bacilli on June 24, she was diagnosed to have miliary tuberculosis.Then the intensive therapy with antituber culosis drugs (isoniazid 400mg, rifampicin 450mg, and streptomycin lg, daily) was started. The non specific antibiotics were discontinued; hydrocortisone was tapered and stopped. The next week, she became afebrile and hypoxemia steadily improved. On July 2, she was extubated without difficulty. An ophthalmoscopic examination disclosed the presence of choroidal tubercles. In August, she continued improving and her fetus was also well. The Chest X-ray showed marked improvement, and the level of arterial blood gas under room air was as follows: Pao2, 80.6 Torr, Paco2, 34.0 Torr, pH 7.470. The number of T-cells increased to 167/mm3, and the PPD skin test became positive. On September 4, she delivered a baby uneventfully, who showed no signs of tuber culosis. From the experience with this case, the following three points may be emphasized. 1.Miliary tuberculosis associated with acute respiratory failure is difficult to be diagnosed and to be differentiated from other respiratory diseases including ARDS. 2.As cellular immunity during pregnancy is suppressed, miliary tuberculosis of pregnant woman may be more serious, and if untreated, it will be fatal. 3.To determine whether anti-tuberculosis drugs are to be used for a pregnant woman with tuberculosis is difficult, because these drugs have a risk not only for the pregnantwoman but for the fetus.

妊娠の経過中に発症し急性呼吸不全症状を呈した粟粒結核症の1例

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