肺アスペルギローマとサイトメガロウイルス肺炎を併発した顕微鏡的多発血管炎の剖検例

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  • An autopsy case of microscopic polyangiitis complicated with pulmonary aspergilloma and cytomegalovirus pneumonia
  • ショウレイ ハイ アスペルギローマ ト サイトメガロウイルス ハイエン オ ヘイハツシタ ケンビキョウテキ タハツ ケッカンエン ノ ボウケンレイ

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A 71-year-old man was admitted to our hospital because of fever and rapidly progressive renal insufficiency over a month. He had depression and Alzheimer's disease as complications. On admission, his serum creatinine was 5.4mg/dL, and the serum CRP and MPO-ANCA were 18.2mg/dL and 285EU, respectively. A computed tomographic chest scan showed pericardiac effusion and fibrosis in both lower lung fields. Although microscopic polyangiitis (MPA) was inferred from a positive MPO-ANCA, renal biopsy could not be carried out. The initial therapy was started with pulse methylprednisolone therapy, followed by oral administration of prednisolone at the dose of 1mg/kg (60mg/day). As a result, his fever and inflammatory findings disappeared, and renal insufficiency was ameliorated with a smooth recovery and the pericardial effusion was markedly diminished. However, on the 18th hospital day, chest radiography revealed a nodular shadow in the right lung. Fungus infection was suspected because his serum beta-D-glucan level was extremely high (above 999pg/mL). Mikafungin, therefore, was started at a dose of 75mg/day and then, the dose was increased up to 300mg/day. Nevertheless, he finally died of respiratory failure on the 26th hospital day.<br>The autopsy findings revealed a cavity of 4.0×3.0×3.0 centimeters in size in the upper lobe of the right lung. There was a great number of fungal threads with a septal wall branched in a Y-shaped figure around the cavity, thus indicating pulmonary aspergilloma. Intranuclear inclusion bodies staining positive for cytomegalovirus were observed in all the lung fields, suggestive of a cytomegalovirus infection.<br>In the kidney, a cellular crescent formation was noted in the majority of glomeruli showing crescentic glomeluronephritis, compatible with MPA.

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