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< 慢性過敏性肺炎の病態を呈した超硬合金肺 | メイン | 小心民の記 >
2008.12.02 19:30 |  診療  |  その他（医療関連）  |  ミチバ  | 推薦数 : 2

超硬合金吸入の関与が疑われたＮＳＩＰ

・本日は当直開けで外来，その後会議で水島へ行き2時間してまた，病院にもどり，回診，診断書等書類書き．．．もーっ，疲れますわっ．

・本日も，超硬合金シリーズでいきたいと思います．（何か，超合金のオモチャみたい）以下の抄録は，千葉医学雑誌79巻1号（2003年2月）に載っていた物です．

超硬合金吸入の関与が疑われたＮＳＩＰの1例

重田文子，黒田文伸

  症例は51歳女性．１５年間金属研磨に従事し，１０年前より乾性咳嗽を自覚していたが胸部レントゲンでは異常所見は認められなかった．平成13年1月より胸痛，呼吸困難(H-JⅢ)を自覚したため3月前医受診し，胸部レントゲンにて下肺野優位にスリガラス陰影が認められた．超硬合金吸入の関与する間質性肺炎を疑われたため4月当科紹介入院となった．胸腔鏡下肺生検を施行しNon-Specific Interstitial Pneumonia(Ⅲ型)と診断し，肺組織の元素分析ではタングステン，珪素，アルミニウムを検出した．６月ステロイド40mg/日より開始．下肺野に一部網状影は残存するも胸痛，呼吸困難は軽快し，胸部レントゲンにてスリガラス陰影は改善した．12月現在ステロイド5mg/日まで減量．増悪傾向は認められていない．

 

・間質性肺炎と言えば，Liebowの分類を懐かしく思います．私が最初に学会発表したのが間質性肺炎でした.私の発表の数席まえのDr.が「間質性肺炎」の発表をされていたら，（後日教授になる）偉い呼吸器の先生が「それは，間質性肺炎ではないんじゃないですか？」といった質問をされました．実は，私もきいていて「あれっ」と思ったのですが，そういう根本的な質問を自分の時にされたらどうしようかと心臓バクバクでした．でも無事に終わりホッ．下に，懐かしの分類を貼り付けておきます．

病理学的分類：Liebow（1968）の分類

  1. 通常型間質性肺炎（UIP: usual interstitial pneumoniae）

  2. 閉塞性細気管支炎を合併したびまん性肺胞障害（BIP: bronchiolitis obliterans and diffuse alveolar damage）

  3. 剥離型間質性肺炎（DIP: desquamative interstitial pneumoniae）

  4. 巨細胞性間質性肺炎（GIP: giant cell interstitial pneumoniae）

  5. リンパ性間質性肺炎（LIP: lymphoid inerstitial pnumoniae）

  ・現在間質性肺炎の病理像は以下の7つに分類されています．

  1. UIP

  2. NSIP

  3. OP

  4. DIP

  5. RP

  6. DAD（diffuse alveolar damage）

  7. LIP

  詳しくは，以下のWebsiteをどうぞ．

http://www.nanbyou.or.jp/sikkan/076_i.htm

・ＮＳＩＰは非特異性間質性肺炎と訳されます．今回言いたいのは，病理像でＮＳＩＰとでても，すぐ「特発性」間質性肺炎と診断してはいけない，何らかの職業・環境因子の検索が必要ということです．まあ，あたりまえの事ですが．．．

・今日は早く帰って，寄島のお酒を飲んで早めに寝ます．

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単純写真やCTをわからないながら読み、ふつうの肺炎に見えなかったら間質性肺炎と即断し、すぐにステロイド投与をはじめてしまう臨床医が今でも結構多いのにびっくりします。

肺気腫に合併した肺炎は蜂巣肺、蜂窩肺とよく似ているし、すりガラスが主体の肺炎や気管支血管束に沿うNSIPと似た肺炎もあるし、やはりthin section CTで診断を絞り込むまで即断はいけませんよね。

一番恐ろしいのは肺結核を間質性肺炎と言ってステロイドを使われることでしょうね。

例外は急速に容積減少が進み呼吸不全に陥るAIPぐらいでしょう。このときばかりは臨床所見とベッドサイドのポータブル単純写真のみでステロイドを直ちに使用せざるをえませんが。

当院では胸部単純写真をオーダーする気軽さで緊急胸部CTを受けています。対応するほうはしんどいけどやむをえないと思っています。（腹部も緊急エコーより緊急CTのほうが多いはずです）

＞Paul Carpenterさま，コメントありがとうございます．緊急でＣＴができて，読影していただけるなんて，とってもうらやましい限りです．
仰るとおり，肺気腫に合併した肺炎は，他疾患と鑑別が難しいですね．
わたしは，間質性肺炎の治療に関しては，よっぽどでない限り，ステロイドを使うのはびびります．（逆に気管支喘息に対しては，結構「気楽」に使っております・・・まあ，使う量・期間が全然違いますね）
written by Paul Carpenter / 2008.12.03 07:52
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