新型コロナウイルス感染を契機に発症した気管支動脈瘤破裂による呼吸不全に対しVV–ECMOを導入し救命し得た1例(Alveolar hemorrhage due to rupture of multiple bronchial aneurysms complicated with corona virus disease 2019 successfully treated with veno–venous extracorporeal membrane oxygenation: a case report)

要旨 気管支動脈瘤は稀な疾患であり，気管支動脈瘤破裂は致死的大量喀血の原因となりうる。症例は69歳の男性。呼吸困難と右胸痛，喀血を主訴に当院に搬送された。来院時38℃台の発熱がありSARS–CoV–2抗原検査が陽性であったためcoronavirus disease 2019（COVID–19）と診断した。搬送時より低酸素血症が顕著であり直ちに迅速導入気管挿管し人工呼吸管理を開始したが，危機的低酸素血症が遷延していたため緊急でveno–venous extracorporeal membrane oxygenation（VV–ECMO）を導入した。呼吸状態が安定したのちに喀血の原因検索目的に胸腹部造影CT検査を施行したところ，左右気管支動脈共通幹に動脈瘤を認めた。気管支動脈の血管造影検査を行い，責任病変を特定して経皮的塞栓術を行った。第7病日にVV–ECMO，続いて人工呼吸管理を終了し，理学療法などを行い第14病日に自宅退院した。本症例ではCOVID–19感染を契機に未診断の多発気管支動脈瘤が破裂したことで発症した危機的低酸素血症に対してVV–ECMO導入により患者の救命に成功した。COVID–19は血管内皮障害に伴って気管支動脈瘤破裂を引き起こす可能性があり，注意が必要である。 ABSTRACT Bronchial aneurysms are rare and their rupture can cause massive hemoptysis which is potentially fatal. Coronavirus disease 2019 (COVID–19) may contribute to such rupture. We present the case of a 69–year–old man referred to our hospital because of right chest pain and dyspnea. A COVID–19 antigen test was positive. Moreover, the patient was severely hypoxemic and we initiated him on a ventilator with rapid sequence intubation. Thereafter, his hypoxemia and hypercapnia worsened. Veno–venous extracorporeal membrane oxygenation (VV–ECMO) was introduced. A thoracoabdominal contrast–enhanced computed tomography scan was performed to examine the lung and bronchial aneurysms were found. We believed that rupture of the bronchial artery aneurysm had caused alveolar hemorrhage. Hence, we performed a coil embolization. On Day 7, VV–ECMO and ventilatory management were completed, and he was discharged on Day 14. In this study, we describe a case of severe hypoxemia associated with alveolar hemorrhage due to rupture of multiple bronchial artery aneurysms complicated by COVID–19. VV–ECMO was urgently introduced, and endovascular treatment was successful in saving the patient’s life. COVID–19 can cause the rupture of bronchial aneurysms associated with vascular endothelial damage and should be treated with caution.