ニューモシスチスとサイトメガロウイルス肺炎による重症呼吸不全に対しECMOを用いて救命したHIV患者の1症例(Severe respiratory failure with Pneumocystis jirovecii and cytomegalovirus pneumonia in an HIV–positive patient treated successfully by extracorporeal membrane oxygenation)

要旨 Anti–retroviral therapyの登場によりhuman immunodeficiency virus（HIV）患者の予後は改善し，ICU管理を要したHIV患者と非HIV患者の死亡率は差がなくなってきた。重症呼吸不全を来したHIV患者に対しextracorporeal membrane oxygenation（ECMO）を導入し救命した報告が散見されるが，本邦からの報告は少ない。症例は50歳の男性，1か月半前にpneumocystis pneumonia（PCP）発症を契機にHIV感染症が判明した。PCP治療後，抗HIV薬開始後に再度呼吸困難が出現し，PCP，cytomegalovirus肺炎，rhinovirus肺炎の診断で入院した。入院後，急性呼吸窮迫症候群により呼吸状態はさらに悪化し，第3病日に人工呼吸器，第8病日にECMOを導入した。その後ECMO，人工呼吸器を離脱し，ICUを退室，第67病日に腸管Kaposi肉腫に対する化学療法目的に転院した。HIV患者はimmunocompromised hostであり感染症による重症呼吸不全を発症しうるが，基本的には抗HIV薬で免疫能は可逆的な病態であるためECMOの適応を考慮すべきである。 ABSTRACT Severe respiratory failure (SRF) in human immunodeficiency virus (HIV)–positive patients used to be considered a contraindication for extracorporeal membrane oxygenation (ECMO) due to the poor prognosis. Thanks to the progress of anti–retroviral therapy (ART) and ECMO management, some HIV–positive patients with SRF have been successfully treated using ECMO. However, such reports from Japan are still scarce. We report herein a 50–year–old, HIV–positive, male patient with SRF due to Pneumocystis pneumonia (PCP) who was rescued with ECMO. He newly received the diagnosis of HIV and PCP a month and a half ago and started ART after PCP treatment. However, his respiratory condition worsened, and he was readmitted. Pneumocystis jirovecii, cytomegalovirus, and rhinovirus were detected in a bronchoalveolar lavage. His respiratory condition deteriorated and required mechanical ventilator (MV) support on day 3 and veno–venous ECMO on day 8. After ECMO support for six days, his respiratory condition improved. MV support was discontinued on day 31. Gastric Kaposi sarcoma was found, and the patient was transferred to another hospital for chemotherapy. One year after discharge, the patient was reportedly in good health. SRF in HIV–positive patients may be reversible, and indications for ECMO therapy must be considered on an individual basis.