田中 保平

BACKGROUND Inferior vena cava (IVC) injury is a potentially fatal injury with a high mortality rate of 34-70%. In cases in which the patient's condition is stable, diagnosis by computed tomography (CT) is the criterion standard. Findings on CT include retroperitoneal hematoma around the IVC, extravasation of contrast medium, and abnormal morphology of the IVC. We report a case of an IVC injury that could not be diagnosed by preoperative CT examination and could not be immediately detected during laparotomy. CASE REPORT A 73-year-old woman had stabbed herself in the neck and abdomen at home using a knife. When she arrived at our hospital, we found a stab wound several centimeters long on her abdomen and a cut approximately 15 cm long on her neck. We activated the massive transfusion protocol because she was in a condition of hemorrhagic shock. After blood transfusion and blood pressure stabilization, contrast-enhanced computed tomography (CT) revealed a small amount of fluid in the abdominal cavity. An otorhinolaryngologist performed successful drainage and hemostasis, and a laparotomy was performed. Gastric injury and mesentery injury of the transverse colon were identified and repaired with sutures. Subsequent search of the retroperitoneum revealed massive bleeding from an injury to the inferior vena cava (IVC). The IVC was repaired. Postoperative progress was good, and she was discharged from the hospital 65 days after her injuries. CONCLUSIONS We experienced a case of penetrating IVC injury, which is a rare trauma. Occult IVC injury may escape detection by preoperative CT examination or during laparotomy.

BACKGROUND Centipede envenomation is usually mild, but a review of the existing literature revealed a more serious course in a small proportion of patients. In fact, necrotizing soft-tissue infections have been reported following centipede stings in a small number of cases and require early diagnosis and treatment because of a high mortality rate. CASE REPORT A 78-year-old man was stung by a centipede on the left abdomen. Treatment with antimicrobial agents was started due to cellulitis, but extensive erythema developed from the left chest to the left buttock. Six days after being stung, he visited our hospital. Necrotizing soft-tissue infection was diagnosed and treated immediately with antibiotics and debridement on the left side of the abdomen and chest. Group A Streptococcus was detected in the fascia. The wound was left partially open and washed daily, resulting in gradual improvement of the wound condition. On hospitalization day 8, the open wound was able to be closed. Antimicrobial therapy was completed on hospitalization day 16. The patient showed good progress. CONCLUSIONS Centipede stings are not rare in tropical and subtropical regions, and most occurrences of centipede envenomation cause only local symptoms. However, we believe that even wounds caused by centipedes should be monitored, given the possibility of subsequent severe infection, as in the present case. In addition, the causative organisms identified in the present patient with necrotizing soft-tissue infection following a centipede sting were commensal bacteria of the skin. Future research is thus needed to clarify the relationship between these causative organisms and centipedes.

50歳代男性。トラックを運転中, 停車していたトラックに追突して受傷した。精査のComputed tomography (CT) にて両側外傷性気胸・骨盤骨折に加えて左総頸動脈の造影途絶を認めた。左内頸動脈および左外頸動脈は造影されていた。頭蓋内に梗塞所見はないため慎重に経過観察していたが, 来院14時間後に右片麻痺と意識レベルの低下が出現した。magnetic resonance imaging (MRI) で左中大脳動脈領域の脳梗塞を認めた。骨盤骨折の手術後から抗凝固療法を開始した。失語と麻痺は残存したが神経症状は増悪なく経過し, 約2カ月後に転院した。鈍的外傷による総頸動脈閉塞はまれな疾患であるが, 神経症状出現率・死亡率がともに高率である。治療として抗血小板薬の有用性が報告されているが, 多発外傷の患者においては出血増悪によるリスクも加味する必要があり, 治療には今後さらなる検討が必要と考えられた。

症例は40歳代男性。仕事中に弾き飛ばされた3kgのアルミ塊が胸腹部に当たり受傷した。造影CTで肝内側区域に著明な血管外漏出像を伴う日本外傷学会分類IIIbの肝損傷を認めた。経カテーテル動脈塞栓術で肝動脈の一部を塞栓して止血が得られたため, 非手術治療 (以下NOM) を選択した。しかし入院6日目に胆汁性腹膜炎を併発し, 開腹ドレナージとENBD留置を行い, いったん全身状態は改善した。その後, 腹痛と発熱が再燃し, CTで肝壊死と肝膿瘍を認めたため経皮的ドレナージを施行したが, ドレナージ後も胆汁漏は持続したため肝左葉切除術を施行し, 最終的に良好な経過を得た。 肝損傷に対するNOMの成功率は高いが, NOM中に合併症のため手術が必要になる症例も存在する。特に重症度が高い損傷は合併症の頻度が高く, 手術が必要となる可能性も高いため, 厳重な経過観察と機を逃さぬ対応が必要なことを改めて認識した。

A 77-year-old man was admitted to a regional hospital to undergo investigation of abnormal electrocardiographic findings. Coronary angiography revealed 99% stenosis of the right coronary artery(RCA) segment 3 and 75% stenosis of the left anterior descending artery (LAD)segment 7. Left ventriculography revealed an aneurysm at the inferior wall of the left ventricle. On computed tomography and echocardiography, a saccular aneurysm at the inferior wall, 15 mm in diameter, was observed. Under the suspicion of a ventricular false aneurysm resulting from myocardial infarction, aneurysmectomy, patch closure of the aneurysmal orifice and coronary artery bypass grafting to the LAD and RCA were performed. No pericardial adhesion to the ventricular aneurysm was observed. His postoperative course was uneventful, and he was discharged from the hospital on the 28th postoperative day in good condition. The pathological examination revealed residual cardiomyocytes with the aneurysmal wall.