熱傷患者における真菌感染症につき検出された真菌株の薬剤感受性を測定し,投与されたfluconazole (FLCZ)が有効血中濃度を維持しているか,臨床的効果が得られているかについて検証を行った。1997年10月～1998年12月の期間,当院熱傷センターに入院した総熱傷面積20%以上の患者18例の熱傷患者から同定された真菌59株につき酵母真菌薬剤感受性キットを用いて抗真菌薬,FLCZ, amphotericin-B (AMPH-B), flucytosine (5-FC)のMICを測定した。Candida albicans群とnon-albikans群のMIC₈₀値はFLCZ (5.06vs 37μg/ml), AMPH-B (0.80vs 0.48μg/ml),5-FC (<0.125vs 1.79μg/ml)となり,FLCZはC. albicansに対しMIC値8μg/mlを示す菌株が23.7%出現し,non-albikans群では40%以上の株がFLCZに対し耐性を示していた。FLCZの血中濃度は深在性真菌症が診断された6例に経日的にそのトラフ値をHPLC法にて測定した。プロトコール通り投与が行われた4例では投与後3日目には8μg/mlを越え,以後そのレベルを維持した。FLCZを投与された6例の血中β-Dグルカン値の推移は半量投与を含む4例では正常域内または20pg/ml近くまでの下降傾向が認められた。現在のFLCZ投与法でC. albicansに対してはMIC₈₀値5.06μg/mlを十分越える血中濃度を維持することができており,それなりの治療効果も得られているが,今後C. albicansでも抵抗性を示す菌株に対応するためFLCZの維持量の設定も300～400mg/dayをも検討すべきであると考えられた。non-albikans群では大半の株が耐性状態にありAMPH-Bなど他の抗菌薬を検討すべきと考えられた。

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目的:クラッシュ症候群の長期予後を明らかにする。対象と方法:阪神淡路大震災で受傷直後に東神戸病院に搬入された挫滅症候群のうち追跡可能であった8例に対し調査を行った。徒手筋力テストなどの神経学的身体所見を主とする診察と,日常生活動作の問題について面接による聞き取り調査を行った。5例に対しては挫滅部位のCTを施行した。結果:震災後4年経っても,挫滅部位は筋の萎縮を認め,筋力低下も残していた。足関節の機能については背屈だけでなく底屈も障害されていた。足関節の拘縮,足趾の変形を認める例もあった。日常的には全例歩行は可能であったが,「しゃがむ」「坂道,階段を降りる」ことの不自由さを認めた。知覚障害は急性期よりは改善しているものの全例で残存していた。挫滅部位のCT所見では筋の萎縮,脂肪変性を認め,1例では筋肉内の石灰化を認めた。機能障害の強い例と,比較的機能が保たれた例との比較では,血清CPKの差は認めず,リハビリテーションの期間は機能障害が強い例で長かった。機能障害の強い例ではCTで筋の萎縮が著しかった。結語:挫滅症候群の長期機能予後は決して楽観できるものではなく,長期的なフォローアップが必要と考えられた。

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洗浄回収式自己血輸血施行例において自己血輸血による血中サイトカインの影響について検討することを目的とした。15例の腹腔内出血例を,SATを行った(A)群7例と,同種輸血を行った(B)群8例の2群に分けた。術前,術後第1病日(POD 1)およびPOD 3に末梢血を採取し,IL-6, IL-8, TNF-α, IL-1raについてELISA法を用いて測定した。血中IL-6値はA群術前141.6±38.6pg/ml(平均±標準誤差),POD 1 369.1±53.2pg/mlであった(術前と比べてp<0.05)。 POD 3には121.0±7.3pg/mlと減少する傾向がみられた。B群は術前120.1±59.4pg/ml, POD 1 235.9±57.4pg/mlとA群と同様に上昇したが,その増加はA群と比べて軽度であった。B群もPOD 3は123.2±16.1pg/mlと減少する傾向がみられた。血中IL-8値は術前A群72.7±22.9pg/mlからPOD 1 237.9±13.5pg/mlに,B群は術前56.4±25.0pg/ml, POD 1 41.4±15.6pg/mlと変化はなかった。POD 1の両群間の値を比較すると,A群が有意に高値を示した(p<0.05)。血中TNF-α値はA群の術前値が13.6±2.1pg/ml, POD 1は13.7±2.8pg/mlで,B群も術前は10.9±2.5pg/ml, POD 1は17.1±4.9pg/mlとほとんど変化なく推移し,両群ともに正常範囲内での変動であった。A群の血中IL-1ra値は,術前が927.5±230.3pg/ml, POD 1は698.7±208.5pg/mlであった。B群は術前が1,239.4±361.0, POD 1に284.2±147.7と減少した。以上から,SATによりIL-8が活性化されることが示されたが,自己血輸血に伴う炎症反応などの副作用はなく,その原因は出血あるいは回収・洗浄システムによる赤血球の溶血が関与していることが推察された。

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A 24-year-old woman was diagnosed with acute disseminated encephalomyelitis (ADEM) after giving birth. She complained of ataxic weakness in her four limbs and difficulty in swallowing. Magnetic resonance imaging (MRI) T2 weighted images taken after admission revealed multiple areas of high intensity, mainly in the brain stem and cerebral white matter. The following day, the patient was admitted to the ICU because of respiratory failure, bradycardia and hypotension. She received two courses of methylprednisolone by pulse dose intravenous administration and plasmapheresis. The patient gradually recovered. ADEM should be recognized as a life-threatening disease that may present after a woman has given birth. MRI images of the brain and spinal cord are useful for the diagnosis of acute phase ADEM. Early diagnosis and treatment are essential for a good prognosis in cases of ADEM.

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In recent years, the development of secondary brain damage and the derangement of neurochemical parameters have been monitored by microdialysis in patients experiencing severe head injuries. Glycerol is regarded as a potential marker for membrane phospholipid degradation and can provide information on the integrity of the blood brain barrier. We introduce a case in which a marked elevation of interstitial glycerol was induced by the exogenous administration of a glycerol-containing agent. A 25-year-old man who had been in a motorcycle accident was admitted to our hospital with a unilateral dilated and fixed pupil and a Glasgow Coma Scale score of three. Computed tomographic scans showed a large left subdural hematoma, a subsequent midline shift, and generalized edema. An emergency craniotomy was performed to remove the hematoma. The patient was then prepared for multisensory monitoring using microdialysis. A microdialysis catheter was inserted in the left frontal lobe. After a routine enema (containing 85% glycerol), a marked increase in the amount of glycerol within the dialysate was measured. This event occurred while the patient was in as stable a condition as could be expected, under the circumstances. An increase in interstitial glycerol in the injured tissue is most likely due to an impaired blood-brain-barrier. Thus, the interstitial glycerol concentration was corrupted by the exogenous glycerol, causing the marker properties of interstitial glycerol to become questionable. Consequently, the administration of glycerol, which is a frequent constituent of various infusions and emulsions, could promote secondary brain damage by adversely shifting osmotic gradients.

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An 81-year-old woman with no history of coagulation disorder was admitted due to swelling and pain in the right thigh. Computed tomography (CT) and magnetic resonance imaging (MRI) showed hemorrhaging in the muscles of the right thigh. Abdominal CT during hospitalization retroperitoneal bleeding. Laboratory examination revealed rapidly progressive anemia, prolonged activated partial thromboplastin time (aPTT), markedly decreased factor VIII activity, and positive factor VIII inhibitor titer. She was diagnosed with coagulopathy due to spontaneously acquired factor VIII inhibitor. Her bleeding did not respond to the infusion of factor VIII concentrate, but was successfully treated by activated prothrombin complex concentrate (aPCC) and PCC. To reduce the production of factor VIII inhibitor, an immunosuppressive regimen, including prednisone and cyclophosphamide, was started. Inhibitor titer gradually decreased and no further bleeding occurred, but the patient died of sepsis caused by a nosocomial airway and urinary tract infection. This suggests that the dose of immunosuppressive drugs should be lower than in the ordinary regimen in such elderly patients.

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A 21-year-old man lost control of his bicycle and crashed into a guardrail. He was admitted to a local hospital the next day with severe abdominal pain. He was treated for acute pancreatitis diagnosed based on abdominal tenderness and increased serum amylase. Six days after the accident, he was transferred to our hospital due to elevated temperature and total bilirubin. Computed tomography (CT) showed a large cystic mass occupying the second and third portions of the duodenum, a swollen diffusely pancreas, and pancreatic duct dilation. He was diagnosed with traumatic intramural hematoma of the duodenum and treated by nasogastric suction and parenteral fluid administration. Percutaneous transhepatic gall bladder drainage (PTGBD) was done to decompress the bile and pancreatic ducts due to hematoma around the duodenal papilla. The patient's condition gradually improved and a CT scan 24 days after the accident showed the hematoma had resolved. PTGBD thus appears to be very useful in conservative by treating duodenal intramural hematoma associated with pancreatitis and cholecystitis.

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