今日の臨床サポート

脳膿瘍

著者: 原田壮平 東京大学医学部附属病院 感染制御部

監修: 具芳明 東京医科歯科大学大学院医歯学総合研究科 統合臨床感染症学分野

著者校正/監修レビュー済:2021/08/04
患者向け説明資料

概要・推奨   

  1. 頭痛と局所神経脱落症状(片麻痺、嚥下障害、視野障害など)がある患者においては、発熱の有無によらず脳膿瘍の可能性を検討することが勧められる(推奨度1)
  1. 頭痛と局所神経脱落症状(片麻痺、嚥下障害、視野障害など)がある患者においては、血液検査での白血球数の増加やCRP値の上昇がない場合でも脳膿瘍の可能性を検討することが勧められる(推奨度1)
  1. エイズ患者で頭蓋内占拠性病変を認めた場合は脳トキソプラズマ症、原発性中枢神経リンパ腫、進行性多巣性白質脳症を主な鑑別診断と考えて精査・加療を行うことが勧められる(推奨度1)
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薬剤監修について:
オーダー内の薬剤用量は日本医科大学付属病院 薬剤部 部長 伊勢雄也 以下、林太祐、渡邉裕次、井ノ口岳洋、梅田将光による疑義照会のプロセスを実施、疑義照会の対象については著者の方による再確認を実施しております。
※薬剤中分類、用法、同効薬、診療報酬は、エルゼビアが独自に作成した薬剤情報であり、
著者により作成された情報ではありません。
尚、用法は添付文書より、同効薬は、薬剤師監修のもとで作成しております。
※薬剤情報の(適外/適内/⽤量内/⽤量外/㊜)等の表記は、エルゼビアジャパン編集部によって記載日時にレセプトチェックソフトなどで確認し作成しております。ただし、これらの記載は、実際の保険適用の査定において保険適用及び保険適用外と判断されることを保証するものではありません。また、検査薬、輸液、血液製剤、全身麻酔薬、抗癌剤等の薬剤は保険適用の記載の一部を割愛させていただいています。
(詳細はこちらを参照)
著者のCOI(Conflicts of Interest)開示:
原田壮平 : 特に申告事項無し[2021年]
監修:具芳明 : 特に申告事項無し[2021年]

改訂のポイント:
  1. 定期レビューを行った(変更なし)。

病態・疫学・診察

疾患情報(疫学・病態)  
  1. 脳膿瘍とは、脳実質内に細菌が感染して膿瘍が形成された頭蓋内の局所性感染症である。限局した範囲の脳実質炎に始まり、時間とともに血行良好な隔壁に隔てられた膿瘍の形成に至る。隣接する組織からの炎症の波及(中耳炎・副鼻腔炎など)や、血流感染などが原因となる。
  1. 米国では、1年に人口10万人当たり0.3~1.5人が罹患し、頭蓋内占拠性病変の約2%を占める。
  1. いかなる年齢でも罹患し得るが、なかでも前青年期や中年に多い。
  1. 罹患者の死亡率は約25%にのぼり、治癒例でも30~55%でけいれん、持続的神経脱落症状、行動変容などの神経学的後遺症を残す。
問診・診察のポイント  
  1. 発症の背景にある基礎疾患を疑わせる症状、病歴、身体所見がないか確認する。

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文献 

著者: C Seydoux, P Francioli
雑誌名: Clin Infect Dis. 1992 Sep;15(3):394-401.
Abstract/Text Thirty-nine cases of brain abscess diagnosed since the advent of the computed tomographic (CT) scan were analyzed for factors influencing the outcome. The mortality rate was 13%, and severe sequelae were present in 22% of the survivors. The mean delay between occurrence of the first symptoms and hospitalization was significantly shorter for the 12 patients with poor outcome (death or severe sequelae) than for the 25 who recovered (fully or with moderate sequelae). Moreover, severely impaired mental status and neurological impairment at admission were associated with a poor outcome in terms of both mortality and sequelae. In all cases with fatal outcome or severe sequelae, the diagnosis was made and treatment was initiated within 24 hours of admission. There was no apparent correlation between the outcome and the presence or type of predisposing factors, the radiological, biological, or microbiological findings, or the treatment modalities. Thus, with the advent of the CT scan and the possibility of early diagnosis and treatment, the prognosis of brain abscess appears to be mainly determined by the rapidity of progression of the disease before hospitalization and the patient's mental status on admission.

PMID 1520783  Clin Infect Dis. 1992 Sep;15(3):394-401.
著者: Eric C Leuthardt, Franz J Wippold, Mark C Oswood, Keith M Rich
雑誌名: Surg Neurol. 2002 Dec;58(6):395-402; discussion 402.
Abstract/Text BACKGROUND: Diffusion-weighted MR imaging (DWI) has recently shown promise in differentiating ring-enhancing lesions such as brain abscess and malignant neoplasm. The ability of DWI to strongly suggest brain abscess enables a neurosurgeon to alter stereotactic planning to optimize diagnosis. We report our experience with DWI in 5 patients with lesions on MR imaging and review the literature to assess the usefulness of this technique in the preoperative evaluation of cerebral abscess.
METHODS: The MR images of 5 patients presenting with ring-enhancing lesions that ultimately proved to be brain abscesses were retrospectively reviewed. In addition to standard MR sequences, trace DWI and apparent diffusion coefficient (ADC) calculations were performed on all patients. Additionally, 15 recently published articles or references in press concerning DWI in cerebral abscesses were reviewed.
RESULTS: All lesions were markedly hyperintense on DWI and had diminished ADC. Thirty-eight of 39 previously reported abscesses were hyperintense on DWI with reduced ADC. Of 165 nonpyogenic lesions with DWI findings, 87 were hypointense or isointense, 78 lesions had variable hyperintensities, and few manifested the degree of hyperintensity observed with abscesses. Most of these included chordomas and epidermoids, which are not likely to be confused with abscesses.
CONCLUSIONS: Restricted water diffusion, as indicated by hyperintensity on DWI and low ADC, in ring-enhancing lesions assists in differentiating brain abscess from necrotic tumor. This information facilitates stereotactic surgical planning: abscesses should be preferentially centrally aspirated, whereas necrotic brain tumors should have diagnostic tissue biopsied from cavity walls. Although not definitive for brain abscess, restricted water diffusion is an important MR imaging sign and is useful in neurosurgical treatment strategies for ring-enhancing lesions.

PMID 12517619  Surg Neurol. 2002 Dec;58(6):395-402; discussion 402.
著者: A Antinori, A Ammassari, A De Luca, A Cingolani, R Murri, G Scoppettuolo, M Fortini, T Tartaglione, L M Larocca, G Zannoni, P Cattani, R Grillo, R Roselli, M Iacoangeli, M Scerrati, L Ortona
雑誌名: Neurology. 1997 Mar;48(3):687-94.
Abstract/Text OBJECTIVE: To identify disease patterns in AIDS-related focal brain lesions (FBL) and to design a decision-making strategy for differential diagnosis.
DESIGN: Prospective study. Probabilities of CNS disorders were calculated using Bayes' theorem according to clinical variables (mass effect at CT or MRI, Toxoplasma serology, anti-Toxoplasma prophylaxis) and to the results of polymerase chain reaction (PCR) assays.
PATIENTS: 136 consecutive HIV-infected patients with a definitive diagnosis of FBL-causing disorder observed from 1991 to 1995 in a single clinical setting.
INTERVENTIONS: Patients underwent empiric anti-Toxoplasma therapy. After 3 weeks, patients with progressive/stable disease underwent brain biopsy. In 66 patients Epstein-Barr virus (EBV)-DNA, JC virus (JCV)-DNA, and T gondii-DNA amplification was performed by PCR in CSF. Diagnostic criteria were histopathologic examination of bioptic or autoptic tissue specimens for all disorders and complete/partial resolution of FBL after empiric therapy for toxoplasmic encephalitis (TE).
RESULTS: Neuroradiologic characteristics did not discriminate between TE and primary CNS lymphoma (PCNSL). Probability of TE was 0.87 in Toxoplasma-seropositive patients with mass effect who were not receiving anti-Toxoplasma prophylaxis, but only 0.59 if prophylaxis was performed. In seronegative patients with mass effect, the likelihood of PCNSL was 0.74. If EBV-DNA or T gondii-DNA tests were positive, the probability of PCNSL or TE increased to more than 0.96. The absence of T gondii-DNA did not exclude the possibility of a TE diagnosis. Among FBL without mass effect, the probability of progressive multifocal leukoencephalopathy (PML) was 0.81; this increased to 0.99 if JCV-DNA testing was positive. Sensitivity of brain biopsy was 93%, with a perioperative morbidity of 12% and a mortality of 2%.
CONCLUSIONS: Due to the low diagnostic capability of clinical variables, PCR amplifications in CSF, especially for EBV-DNA and for JCV-DNA, represent, in most cases, an essential step in the differential diagnosis of AIDS-related FBL. This is particularly true in patients with FBL without mass effect or with mass effect and who are either seronegative or undergoing anti-Toxoplasma prophylaxis. Brain biopsy remains a necessary procedure in EBV-DNA-positive cases and in seronegative patients with FBL displaying a mass effect. Positive JCV-DNA testing may obviate the need for brain biopsy in patients with FBL without mass effect. An advanced diagnostic strategy based on combined clinical criteria and PCR tests may allow rapid and accurate identification of patients for prompt brain biopsy or specific therapy.

PMID 9065549  Neurology. 1997 Mar;48(3):687-94.
著者: Alessandra Nicoletti, Alessandro Bartoloni, Vito Sofia, Filippo Bartalesi, Josè Rosado Chavez, Rimberto Osinaga, Franco Paradisi, Jean-Luc Dumas, Victor C W Tsang, Arturo Reggio, Andrew J Hall
雑誌名: Epilepsia. 2005 Jul;46(7):1127-32. doi: 10.1111/j.1528-1167.2005.67804.x.
Abstract/Text PURPOSE: To evaluate the frequency of neurocysticercosis (NCC) in a well-defined prevalent cohort of epilepsy patients in the rural area of the Cordillera province.
METHODS: We carried out a two-phase door-to-door neuroepidemiologic survey in a sample of 10,124 subjects in a rural area of the Cordillera Province, Bolivia, to detect the prevalence of the most common neurologic disorders including epilepsy. A team of health workers administered a standard screening instrument for neurologic diseases; subjects found positive at the screening phase underwent a complete neurologic examination. Epilepsy patients were diagnosed according to the definition proposed by the International League Against Epilepsy (ILAE, 1993). Epilepsy patients identified this way underwent electroencephalographic recording, computed tomography (CT) scan, and serologic evaluation to detect antibodies against Taenia solium by enzyme-linked immunoelectrotransfer blot.
RESULTS: At the end of the survey, we detected 124 defined prevalent epilepsy patients. On the basis of the classification proposed by the ILAE in 1981, partial seizures were the most common type diagnosed (66 patients, 53.3%). Of the 124 patients, 105 underwent CT scan, and a serum sample was taken to detect antibodies against T. solium in 112 patients; for 97 patients, both neuroradiologic and serologic data were available. Considering radiologic, serologic, and clinical features, of these 124 patients, 34 (27.4%) fulfilled the diagnostic criteria for definitive or probable NCC proposed in 2001. Of these 34 patients 24 (70.6%) had partial seizures.
CONCLUSIONS: Our data confirm a high frequency of NCC among a well-defined prevalent cohort of epilepsy patients.

PMID 16026566  Epilepsia. 2005 Jul;46(7):1127-32. doi: 10.1111/j.1528-・・・
著者: Marco T Medina, Reyna M Durón, Lisandro Martínez, Juan Ramón Osorio, Ana L Estrada, Concepción Zúniga, Dora Cartagena, Julianne S Collins, Kenton R Holden
雑誌名: Epilepsia. 2005 Jan;46(1):124-31. doi: 10.1111/j.0013-9580.2005.11704.x.
Abstract/Text PURPOSE: Determination of epilepsy etiology in population-based studies is difficult because of the high cost of diagnostic tests. However, cost-effectiveness may be proven if preventive public-health strategies can be established from the test results. We report an epilepsy population-based study using clinical and laboratory techniques.
METHODS: A medical team administered an epilepsy survey to 88% of the residents by census in the rural county of Salamá, Honduras. Ninety of 100 participants identified with active epilepsy underwent a neurologic examination, video-electroencephalography (video-EEG), brain computed tomography (CT) scan, and serum enzyme-linked immunoelectrotransfer blot (EITB) for cysticercosis. Final diagnoses were based on the International League Against Epilepsy classifications for seizures and epilepsy syndromes. Combined epidemiologic, clinical, video-EEG, neuroimaging, and serum EITB assays were used for the diagnosis of epilepsy etiologies.
RESULTS: Among 6,473 residents surveyed, 151 persons with epilepsy (prevalence rate, 23.3/1,000) were identified, 100 of whom had active epilepsy (15.4/1,000) on the prevalence day. Incidence was determined to be 92.7/100,000. Partial seizures with or without secondary generalization were common (92.2%). Symptomatic epilepsy (62%) was primarily due to neurocysticercosis (37%), perinatal brain damage (8%), post-traumatic (3%), and poststroke (2%). Eight percent were idiopathic, and 30% were cryptogenic (unknown cause).
CONCLUSIONS: Symptomatic epilepsies primarily explained the high prevalence and incidence of epilepsy in Salamá. Integration of video-EEG and brain CT scan with clinical-epidemiologic evaluation was critical for determination of epilepsy etiology. Establishment of specific programs for continuation of epidemiologic surveillance, education, intervention, and long-term follow-up will benefit the Salamá region.

PMID 15660778  Epilepsia. 2005 Jan;46(1):124-31. doi: 10.1111/j.0013-9・・・
著者: V Rajshekhar, M Venkat Raghava, V Prabhakaran, A Oommen, J Muliyil
雑誌名: Neurology. 2006 Dec 26;67(12):2135-9. doi: 10.1212/01.wnl.0000249113.11824.64.
Abstract/Text OBJECTIVE: To determine the contribution of neurocysticercosis (NCC) to the causation of active epilepsy (AE) in a south Indian community.
METHODS: We conducted a door-to-door survey of 50,617 people between the ages of 2 and 60 years in a rural (38,105 people) and urban setting (12,512 people) in the Vellore district of the south Indian state of Tamil Nadu to identify patients with AE. Patients with AE were investigated with a contrast-enhanced CT scan and serologic study using enzyme-linked immunotransfer blot (EITB) for cysticercal antibodies.
RESULTS: We identified 194 patients with AE. The prevalence of AE was 3.83 per 1,000 people, with the prevalence in the urban clusters more than twice that in the rural clusters (6.23 vs 3.04 per 1,000) (p < 0.0001). A diagnosis of NCC was made in 46 (28.4%) of the 162 patients undergoing a CT scan, and EITB was positive in 21 (13%) patients. Overall, 55 (34%) patients were diagnosed with NCC (11 definitive NCC and 44 probable NCC). There was no significant difference in the prevalence of NCC causing AE in the urban (1.28 per 1,000) and rural (1.02 per 1,000) communities.
CONCLUSIONS: NCC is the cause of nearly one-third of all cases of AE in both the urban and rural regions. Extrapolating our results to the country as a whole leads to an estimated disease burden of 1 million patients in India with AE attributable to NCC.

PMID 17190933  Neurology. 2006 Dec 26;67(12):2135-9. doi: 10.1212/01.w・・・
著者: J L Carpenter
雑誌名: Clin Infect Dis. 1994 Feb;18(2):219-26.
Abstract/Text A patient with a brain stem abscess that was cured with medical therapy alone is described. The English-language literature on brain stem abscesses is reviewed. Computed tomography (CT) and magnetic resonance imaging (MRI) have revolutionized the rapidity with which the diagnosis can be made and have markedly changed the prognosis for patients with brain stem abscesses. To my knowledge, all patients whose brain stem abscesses have been diagnosed by MRI or CT have survived although some have had neurological residuals. Patients are usually treated with surgical excision or aspiration along with antibiotics. Our patient was treated with medical therapy alone, and this case represents the fourth reported cure with this treatment modality. Medical therapy may be anticipated to cure patients with brain stem abscesses whose conditions are diagnosed expeditiously with CT or MRI techniques.

PMID 8161630  Clin Infect Dis. 1994 Feb;18(2):219-26.
著者: G E Mathisen, J P Johnson
雑誌名: Clin Infect Dis. 1997 Oct;25(4):763-79; quiz 780-1.
Abstract/Text The past 20 years have seen major advances in the diagnosis and management of brain abscess, with a corresponding improvement in the survival rates. The advances in radiographic scanning, the availability of new antimicrobials, and the development of novel surgical techniques have all contributed to the decreases in associated morbidity and mortality. The relative rarity of brain abscess and the frequent delays in making the diagnosis render this condition a significant challenge for the clinician. A high index of suspicion is required so that effective therapy can be instituted as soon as possible. Close coordination of care between neurosurgeons and infectious diseases specialists is increasingly important in the complicated management of brain abscess. Adequate abscess drainage and appropriate antimicrobial therapy remain the cornerstones of proper treatment of this condition.

PMID 9356788  Clin Infect Dis. 1997 Oct;25(4):763-79; quiz 780-1.

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