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冬季に検出し得た Vibrio vulnificus 感染症の 1 例
ῌuvº 2006 1 ῌ῎ ῏῍ Vibrio vulnificus 1 1) 1) 1) 2) 1) 1) 2) ! 17 5 " 16 #$ 17 11 " 17 #% Vibrio vulnificus &$ '$ ($ )*+,- ./0!12/3450 6718 V. vulnificus &$ 9:;2 7 "<= 9 "">?$ @A 11 " 04B:#C128 /3& 79 D$ $%8 )*EF;G8 2004 11 " 14 $ &'HIJK (Atrina pectinata japonica) H(0LL)MN$ OP*Q+R+S+2?,-=:;T U$ 3 N 11 " 17 16 VWXY,.Z[\2L:]LL/0[\^>8 X1 A 23N$ )*45:6 4_`a :;2 B 73b+28 [=8 20 VW$ 9c:;<:$ = de>b+2?$ ?@AfB8 +g$ =>V 11 " 17 h0[\iOPjCDkEl<= V. vulnificus ? [\8 FmG:&$ n?opqf%rHsN$ It%uvwxy2fB & 7 "<= 9 "9z ^>28 @A$ {|&#C?L\:;2 11 " 04B8 J}~Ky2'~$ ,M$ L>MeNOc+,0 2b9+=g>^$ n1>Ix+PQ^$ M eN)M06^RR2yS+?TU:;2b\28 Key words: Vibrio vulnificus, V. vulnificus infection in winter season, import of fresh fish and shellfishes Vibrio vulnificus &$ )*VW+, :;28 [=n&$ ' ( §S1 X%./0- ./b12/3?$ n[\ 2¨n:$ '~? 20©£+2b.Oª eN0LL)M^$ qf%rHsI 12U$ ny2 7 "<= 9 "9 t%uvwx0671:;28 4 z ^>2?4)$ 6), 7)$ gO=y2b$ '~? 5<'( :+#$ ;2 20©£O+2g>^' (gy« >&1:Y^>Z<=Z;2 eN<=hi[\b#C^>25)8 gR ?$ 45?"S[N> 8 =y2 2n#C& 3 ;G$ 11 " 1 b$ fB\&] 70¡:$ ^ 38.5¡/3? 3 _ &J?¬®:;G$ 12 " 2 &n `fB^gG$ 7\&fBab¢: 54.7¡ ¯?j°<=:^±:;24)8 @A$ ;28 1+¢fBcd£& 3 _`:f {|& 11 "$ nyT^qf%r B12:;2b^>24)8 L$ ¤¥ Hsb+G$ It%uvwxy2fB04B ,.127b&L\:$ ¦>Oe0671f :#C128 1)3) p3qrs² (·830῍0011) ¸¹t 67 TEL: 0942῍35῍3311 !G 5445% FAX: 0942῍31῍7760 I. ῎῏ / 3² 79 D$ $%8 ³ k² iOP´l$ mOP*8 EFn² 1991 )*$ C )s8 Qn² 2004 11 " 14 $ µog>^$ ¶J uv»¼ Vol. 16 No. 1 2006. 1 ³S´. 2 µ¶·o¸¹ Table 1. Laboratory findings on admission. (Atrina pectinata japonica) (Fig. 1) !"#$%%&'( )("#$% 3 11 * 17 16 +,- ."/01234 5"/0% 6 +7- Japan Coma Scale 1 890%0 :9- ;<1=7$>?0@- AB 71/45 mmHg- - !C#?- "DE/ #- $%F 8&G'@ "#$% 4( A )H *+- IJ,/-HKLMN."# B )H / + B ) H * 0 +- : - 1 O 33.2P- 23 68/- AB 87/30- 4- 5 A6- 7- 8Q9:;&- %- ARST< =7- B )H-HKLMN.+U?> CK ?@- IVABW;&/0% ABCD@B X E F- C G H D sulbactam / cefoperazone (SBT/CPZ) 1 g IJKL%HYMZ! (- N 20 +,- OT[PQR%&SH\T6 6]^_`aUb0H1$% 0H+ST5 (Table 1)c 0H+dARS T<=7- IVAVVAC- CKῌCRP ?@WAeXdUfAYZXC- ghVACi ;&% [\KLc 0H+ Japan Coma Scale 1, Glasgow Coma Scale 13 8jkc lRjkm- no]pc 5^_%%q`- r]pc ab]p1/ r@- 1O 33.6P- st 20/- 23 76/- AB 74/u mmHg 1OC%&- Ocd[OeU Results Blood chemistry AST (GOT) 725 U/l ALT (GPT) 215 U/l LD 584 U/l ALP 232 U/l T.B 2.44 mg/100 ml D.B 1.41 mg/100 ml TP 4.4 g/100 ml ALB 2.06 g/100 ml UN 45.4 mg/100 ml Crea 1.68 mg/100 ml UA 8.91 mg/100 ml Ca 7.17 mg/100 ml CK 19910 U/l CKMB 381 U/l Amylase 54 U/l Serological tests CRP 6.23 mg/100 ml HBsAg below sensitivity CBC WBC 17 ±102 /ml RBC 374 ±104 /ml Hb 13.3 g/100 ml Ht 37.3 ² Plt 2.8 ±104 /ml Coagulation PT 40 ² FDP 6.4 mg/ml Fib 212 g/100 ml AT-ῌ 11 ² PLG 19 ² Reference limits 13°33 8°42 119°229 115°359 °1.5 °0.6 6.7°8.3 4.0°5.0 8°22 0.6°1.1 3.6°8.0 8.7°10.3 62°287 6°28 50°159 °0.4 40°90 430°570 14°18 40°52 13°36 60°130 °2.5 200°400 84°117 96°117 fg_Ov0- %- stD/wstxh 1% ABCD/7- iR- @BXyj % kzl- {> 4#? (Fig. II. ῐ῍ῌῒ῎῏ 1. ῎῏ῑΐ 2)- {|mnj}v1$% {|mnj SH"7- HCGH 0%%1>7- %123- i~oUp#?- qr ne- STD/ ]sf1 crosis- sR;&!% %- CGHD 1!/0 - SH7SHUb0H1$ panipenem/betamipron (PAPM/BP) 2.0 g/- clin- % 11 * 17 _`_^_ damycin (CLDM) 2400 mg/EF% ' v$%- ST]'01u- t )%%&nuv%- . { | m n j + ! % s R 7- BacT / wD/_`_^_v$%12 ALERT῍ 3D system j SA 8j@SN 8j@ 3- nu7x(ly%"Px ¡¢£`¡ 8S¤¥¦§¨`@ ©- %%&- xzx?{|dUfnu7v) ª 11 * 18 «CGH¬S 0}~"KLMN1$% 11 * 18 - H %&ST% 21>- 0H+© YMZ!(AH'U? /0%ARN+% d- % S11"7O_/0% %- N.Sv)- t2® A7¯Z!%%&- Ax 2 S[\º»¼ Vol. 16 No. 1 2006. C¸7¹ Vibrio vulnificus ,¹D 3 ( # % T Micro Scanῌ Walk Away SI 96 (%568) 2. ῎῏ 1) " !" (%56 # $%&'( )*+ G ,- 3. ῍ῌ ῌ ./'0 %1234,-%56 1) 2) Mi- cro Scanῌ Pos BP Combo 41J %T #234,-j7( +234z, 7( 8 9:#%5;< $=>% ac ":7( 7c 6 56 ?@ABῌCD 5EFGHI 2) .JKLMNOPQLCL( RS TSA 5E => 7( -( TSA SB0( DHL I .JKLMNOPQLC 5ESB T.z%kqrs#( >W3 L0 %TUV%5T( >W3 HK I HK I7( /-#qrsa 0 (RS) .X'0 %T( YV*L+ .Z+D ¡c( TCBS I7( 1 4 mm 23 [B\PK0 ]YV%56 ^( => # S ¢#/45£z#-qrsa 56234,-#_`( Vibrio c (Fig. 3) DHL Iqrs# ab;c TCBS I ./'0 %d 7¤6 ^( >W3 HK I# %56 /-qrs( TCBS I#qrs%234, "7( TGC .efghei j0 k]( # %56 l !7( 8 -_`( +234z,ac "7( 4 6 TGC k¥ #7¦aca( §#8#I7 #7¦7c6 TGC 9 BacT / ALERTῌ 3 D . m n o ,-%56_`( 234 ?p0 %56 TSA 5ESB =>%56 3) %=> TCBS -q 234 z¨a¤c( - TSA 5ESB /-#qrsa c rs%c( nQtuvwB .xyh0 a z ^( T7( l( :{6c Vibrio !"( Micro Scanῌ Walk #9© 5 ªz! Away SI 96 (DADE BEHRING) #|}~T %#( %568) $1#@rL@ 3) (DADE BEHRING) %% Micro Scanῌ 7( Micro Scanῌ Walk Neg BP Combo 3J (DADE BEHRING) # Away SI 96 (#_`( V. vulnificus .@r)« *&( 0.85E' / MacFarland Dq¬ 400500170 ^( U z 0.5 #% 50 ml <d$( :7( 0.5, 1( 3E# NaCl d?\@L/ (%56 ^( 0, 0.5, 1, 3, 8, 10E# 7¦ac O/129 NOBK 10 mg 150 NaCl d?\@L/U z%5T( mg #z_`7( 9©z:{6 ® @w?NOLy O/129 NOBK .xy #_` h0 10 mg 150 mg #z569) " 7( V. vulnificus " 7( (#_` Staphylococcus epidermidis :{6 z qrs# Staphylococcus ab; 4) c( Micro Scanῌ Pos BP Combo 41J (DADE V. vulnificus :7 minocyclin ¯#w3 BEHRING) %T#(% =DK?L°±;²<=¢#>³´?W)*4°a 56 @µ¶z%k2), 3) V. 4) z vulnificus #z#_`7( ·ABz% ( l:71T]µa( %)#@rL@$* Eºfh»¼ Vol. 16 No. 1 2006. 3 4 Fig. 1. Fig. 2. Fig. 3. 4 Atrina pectinata japonica Fig. 4. Pathological analysis of the right-leg muscles obtained from the autopsied patient. Infiltration by inflammatory cells mainly neutrophils, was observed at perivascular and intermuscular areas. Muscle tissues were partially necrotized. (HE stain200) Fig. 5. Microbiological analysis of the right-leg muscles obtained from the autopsied patient Gram negative cocci, and rods were mainly observed. (Gram stain 1000) Red-purple colored change of the lower extremities, and enlarged right lower extremity. Growth of V. vulnificus on Trypticase Soy Agar with 5 Sheep Blood (left) and TCBS Agar (right). Vol. 16 No. 1 2006. ¶·] Vibrio vulnificus i] Table 2. 5 Drug susceptibility test of Vibrio vulnificus and Staphylococcus epidermidis. MIC ( mg/ml³ Vibrio vulnificus Ampicillin Piperacillin Amoxicillin/clavulanic acid Cefoprazon/sulbactam Cefazolin Cefaclor Cefotiam Cefoperazone Cefotaxime Cefpodoxime Ceftazidime Cefozopram Cefepime Cefpirome Cefsulodin Cefmetazole Latamoxef Flomoxef Aztreonam Imipenem Meropenem Levofloxacin Ciprofloxacin Gentamicin Tobramycin Amikacin Minocyclin Sulfomethoxazole/trimethoprim Fosfomycin ´8 ´16 ´8 ´16 ´8 ´8 16 ´16 ´8 ´2 ´8 16 ´8 ´8 µ16 ´16 ´8 ´8 µ16 ´4 ´4 ´2 ´1 ´4 8 32 ´4 ´0.5 ´4 Staphylococcus epidermidis µ8 µ2 8 64 ´8 ´4 ´16 ´8 ´8 µ4 µ2 ´8 16 ´8 ´8 ´4 8 ´2 ´4 µ8 ´4 ´4 µ2 µ4 µ4 ´2 ´8 ´2 ´4 Penicillin G Oxacillin Ampicillin Piperacillin Ampicillin/sulbactam Amoxicillin/clavulanic acid Cefoprazon/sulbactam Cefazolin Cefotiam Cefotaxime Cefpodoxime Cefdinir Cefozopram Cefepime Cefpirome Flomoxef Imipenem Meropenem Norfloxacin Gentamicin Arbekacin Minocyclin Clindamycin Erythromycin Clarithromycin Vancomycin Teicoplanin Sulfomethoxazole/trimethoprim Fosfomycin tamination 1qrl1PQ,-!" ! " #$% & '()*+,-./%0-!123" IV. ῎ 456789.:; S. epidermidis s]+ tuvw1Bxvw0-. #m V. ῏ $%+ oxacillin <,-. =>? vulnificus yi; z?{|}~ @*<AB0 arbekacin, vancomy- Bm1.s7iB 4 4] cin, teicoplanin C+,-!" 7D ,g;],-" V. vulnificus $% (Table 2) AE" i]+d]E1 Evw,-. .g+B. III. ῑ ῌ ῐ ῍ ] 72 HVi]1; FGHIJKLMNOPQ,+ 45RST 70 ;n!+ 100gBT UKLVWXYZ[1E\]^_`ab . 0 ¡¢E1), 10)" B0! c KL+defgB (Fig. 4)" h)ij,+ £¤¥¦1§0¨,-0 s], h)kY7TU7 deh)Y70b +w©0,-. nªd«¬lB,-!c cl (Fig. 5)" Q0 i 3 M®¯1!" #$ V. vulnificus +h)k7,-m1nl V. vulnificus i ] 0 A o ; # p 7 + con- % 0i]°]±d²!1 qrl" s¸¹~9º»¼ Vol. 16 No. 1 2006. 5 ®} ?0¹¹ºº»»¼ 6 V. vulnificus N/H[\)%LDE$a#'%& bw% V. vulnificus - cd&xefy)d(\] )q;( p g"zS0d#' + GA)$LMhi%&a #'%13) !"#$%& " 99{jC)%Xk{lmn D| #'($)!( /[\F}~oZ0p - N/H *)+,&1), 4) - .)(! [\-uF23%&3V)$ V. vulnificus ) /( -u,%&23% D( ) (%& !)( D,qo rstq 01#&23 % - oF$du vwD(%u -xyFz !4"#5# 678* D(%uN u){D( 3V) 9:$(% #;<=>?8@ LM(%[ P #'% PAPM/BP %&(A678* #'%; ;M 5) 9BCD&23 % ;<=>?8@ /H[\|0FbV| p >F_U(} PBP-1a 1b 2 )E'F(D GHI ]%_)~sa#'%&bw% 9BCD))*,%A G678* 9&D(:$$&23 % 4), 11) JK+, -" S. epidermidis MRS Bacterial translocation )% ῏ ῎ 0 17 >l zS 17590505 )( $#&23 V. vulnificus )L(MN7OP ./0Q1#1D&23 % MN7O ;RSMTP&2U#3V)4W%56 P#'+ 789:;X&<YX#'% = 2001 > 1 Z 12 Z-# :;X8[\ ?)]% V. vulnificus V@A/BC^DE F/HI 20 FGH[\ 550 I_` 122 I (22.2a) V. vulnificus &D( ῌῑῐ῍ 1) 2) 3) 4) % bV 5c10 Z 25.6a (78/305) 3V 11c 4Z 18.0a (44/245) #' MN7O)d ( 3V 1c2 Z 5) )JKD 12 I_` 1 I (8.3a) &LMD(%5) - 78e)$N/H[\&D(?7f 7 $N(%12) FghD 2004 6) > 2005 > :;X#MN7Oiij kDA) MN7OiOli&( 7) +PQRS&(% D( N MN7O)L(mT$(U 8) Q1&MN7O 7#4W $'%N$ - VWX ($nA oY0Z[ D#' 9) A\] &pq;#r D D 0/s-0^_+C)+ -tN/H[\-u$v`%& " 6 o¢¼/,§ Vol. 16 No. 1 2006. 10) 2001 Vibrio vulnificus 50: 526῍531 = 1999 Vibrio vulnificus G. 54: 586῍593 0 1998 ¡¢ £¢<¤¥; INFECTION CONTROL 7: 282῍288 ¦ ?§0 1999 Vibrio vulnificus ῌ & ¤ ¨ © ª©«|ῌ o¬ 109: 875῍884 = ®} 2004 :; X¯ L¡ Xk [\?)]% Vibrio vulnificus V @ A / B C ^ ¢ 7: 580῍ 586 £ ¤ ° ¥ :¤¦ 2002 Vibrio vulnificus )% 1 § 76: 63῍66 =¨ ©ª¦« ¬ 2003 Vibrio vulnificus ± 1 x e § 77: 167῍173. ®¯° ±²5 2004 Vibrio ²2³Ey´h)³´ ,µµl¶· .E 53: 933῍939 ¶0¸ 2001 ·¸D¡¢ £² &GQ1)d( Modern Media 47: 272῍ 282 Klontz, K. C., S. Lieb, M. Chreiber, et al 1998 Syndrome of Vibrio vulnificus infections Clini- ABC< Vibrio vulnificus ;#<D 11) cal and epidemiological features in Florida cases 1981ῌ1987 Ann Intern Med 109: 318ῌ323 Jackson, J. J., H. Kropp. 1992 b-Lactam antibiotic-induced release of free endotoxin: in vitro comparison of penicillin-binding protein (PBP)2-specific imipenem and PBP3-specific 12) 13) 7 ceftazidime J Infect Dis 165: 1033ῌ1041 2003 !"#$% &'()*+,- 24: 317ῌ318. ./0 2002 123456 789:!; #< => 84: 554ῌ555 A Case of Vibrio vulnificus Infection Occurring in the Winter Season Rie Horita1), Kouji Hashimoto1), Kazunori Nakata1), Kanta Kikuma2), Kimitaka Sagawa, MD1) 1) 2) Department of Laboratory Medicine, Kurume University Hospital Emergency and Critical Care Medical Center, Kurume University Hospital We report a rare case of Vibrio vulnificus infection that occurred in the winter season. A 79 year-old single male with liver cirrhosis ate raw Atrina pectinata shellfish in his house on November 14, 2004. On November 17 a neighbor discovered him lying in bed, unable to walk due to severe leg pain that had started soon after he had eaten the raw shellfish meat. He was admitted to the Emergency and Critical Care Medical Center of Kurume University Hospital. Physical examination of the patient revealed Japan Coma Scale 1, respiratory rate 20/min, body temperature 33.6?, pulse rate 76/min, blood pressure 74/@ mmHg, red-purple colored change of the lower extremities, and enlarged right lower extremity. The right lower extremity was sectioned in order to relieve the higher pressure. The sectioned leg exhibit a bad smell, necrotized muscles, and exudates. Although intensive therapies were applied, the patient was expired on November 18. Pathological analysis of the right-leg muscles obtained from the autopsied patient showed typical features of V. vulnificus infection. EFGH()IJK Vol. 16 No. 1 2006. 7