Paeniclostridium sordelliiによる毒素性ショックを来した小児腸重積の1例(Toxic shock secondary to Paeniclostridium sordelliseen in a pediatric intussusception)

症例は生来健康だった10歳の女児。入院2日前からの右下腹部疝痛と非血性嘔吐を主訴に前医を受診し，腸重積による腸閉塞で当院紹介となった。入院当日の緊急試験開腹では，重積した回盲部腸管の用手整復のみを行った。敗血症性ショックは術後も進行し，第2病日にバソプレシンを追加し抗菌薬をメロペネムへ変更した。エンドトキシン吸着療法後も全身浮腫と乳酸アシドーシスは進行し，腸管血流障害を疑い，同日夕方に再度試験開腹をした。整復した腸管の一部に壊死がみられ，回盲部を含む色調不良な小腸を約1m切除した。術後代謝性アシドーシスに対して持続血液濾過透析，薬剤不応性ショックに対して体外式膜型人工肺を導入したが，改善はみられず第3病日に死亡した。Paeniclostridium（Clostridium）sordellii（以下P. sordellii）感染症は，急速に進行する全身浮腫と胸腹水，薬剤不応性ショック致死的経過をたどる予後不良な疾患である。本症例では，前述した臨床経過に加え死後2日目に腹水培養からP. sordelliiが検出された。病理所見でも壊死腸管にP. sordelliiを示唆するグラム陽性桿菌の浸潤がみられたため臨床的にP. sordellii感染症と診断した。進行が早く予後不良であることから，疑い症例に対しては輸液と抗菌薬を速やかに開始し，可及的速やかに感染巣の外科的除去を検討することが肝要である。 The patient was a 10–year–old girl who presented with a two–day history of right lower abdominal pain and non–bloody vomiting. The patient was diagnosed with bowel obstruction secondary to intussusception. The patient underwent immediate exploratory laparotomy, and manual reduction of intussusception was performed. Perioperatively, she became hemodynamically unstable and noradrenaline was initiated. On admission day two, vasopressin was added and cefmetazole was escalated to meropenem. Despite additional immunoglobulin and polymyxin B–immobilized fiber column direct hemoperfusion, anasarca and lactic acidosis rapidly worsened. She underwent repeat laparotomy the same evening, and the necrotic ileocecal section was resected. Continuous venovenous hemodiafiltration was initiated postoperatively for worsening hyperkalemia and lactic acidosis. Four hours later, she went into cardiac arrest. Venoarterial extracorporeal membrane oxygenation was introduced; however, her hemodynamics remained unstable, and she died on admission day three. Paeniclostridium sordelliiinfection is a rare but well–known cause of toxic shock with high mortality among previously healthy young individuals. Characteristic features include progressive anasarca, refractory shock, severe leukocytosis, and hemoconcentration. This case was diagnosed clinically based on positive ascitic fluid culture and pathological findings demonstrating invasion of the organism into resected necrotic ileocecum. Immediate intervention is critical during the initial evaluation.