今日の臨床サポート

日本脳炎

著者: 加島雅之 熊本赤十字病院 内科

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:2016/06/30
患者向け説明資料

概要・推奨   

疾患のポイント:
  1. 日本脳炎とは、蚊によって媒介されるフラビウイルス属の日本脳炎ウイルスに感染することで発症する脳炎である。
  1. 通常、日本脳炎ウイルスに感染してもほとんどは無症状または発熱のみであるが、一部の感染者が脳炎症状を呈する。感染症法では4類感染症に属し、本疾患を疑った場合は、ただちに最寄りの保健所に届け出が必要である。
  1. 潜伏期間は、5~16日で、そのころ日本脳炎の流行地への旅行歴を確認する。
閲覧にはご契
閲覧に
  1. 閲覧にはご契約が必要となります。閲覧にはご契約が必要となります。閲覧にはご契約が必要となります。閲覧にはご契約
  1. 確定診断には、髄液中の日本脳炎特異的IgM抗体が有用で、検出された場合はほぼ診断確定といえる。国立感染症研究所ウイルス第一部に検査およびその解釈の相談ができる。
  1. 閲覧にはご契約が必要となります。閲覧にはご契約が必要となります。閲覧にはご契約が必要となります。閲覧にはご契約が必要となります。閲覧にはご契約
  1. 閲覧にはご契約が必要となります。閲覧にはご契約が必要と
閲覧にはご契
閲覧にはご契約
  1. 閲覧にはご契約が必要となります。閲覧にはご契約が必要となります。閲覧にはご契約が必要となります。閲覧にはご契約が必要とな
  1. 閲覧にはご契約が必要となります。閲覧にはご契約が必要となります。閲覧にはご契約が必要となります。閲覧にはご契約が必要となります。閲
閲覧にはご契
閲覧に
  1. 閲覧にはご契約が必要とな
  1. 閲覧にはご契約が必要となります。閲覧にはご契約が必要とな
閲覧にはご契
閲覧にはご契約が必要とな
  1. 閲覧にはご契約が必要となります。閲覧にはご契約が
閲覧にはご契
閲覧にはご契約が
  1. 閲覧にはご契約が必要となります。閲覧にはご契約が必要となります。閲覧にはご契約が必
  1. 閲覧にはご契約が必要となります。閲覧にはご契約が必要となります。閲覧にはご契約
  1. 閲覧にはご契約が必要となります。閲覧
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:
加島雅之 : 未申告[2021年]
監修:具芳明 : 特に申告事項無し[2021年]

病態・疫学・診察

疾患情報(疫学・病態)  
  1. 日本脳炎は、蚊によって媒介されるフラビウイルス属の日本脳炎ウイルスに感染することで発症する。
  1. 感染してもほとんどは無症状または発熱のみで、一部の感染者が脳炎症状を呈する。
  1. 4類感染症に定められており、診断した医師はただちに最寄りの保健所に届け出る。
  1. 日本脳炎ワクチン未接種者または不完全接種者で、夏季や、海外渡航歴がある者の脳炎患者では必ず日本脳炎を考慮する。 エビデンス 
  1. 発症者のほとんどは、小児と高齢者である。
  1. 現在有効な治療法はなく、脳炎を発症した者の死亡率は20~40%であり、また、生存者の45~70%で精神神経学的後遺症が認められる(国立感染症研究所ウイルス第一部)。
問診・診察のポイント  
  1. 日本脳炎ワクチンの接種歴を確認する。

これより先の閲覧には個人契約のトライアルまたはお申込みが必要です。

最新のエビデンスに基づいた二次文献データベース「今日の臨床サポート」。
常時アップデートされており、最新のエビデンスを各分野のエキスパートが豊富な図表や処方・検査例を交えて分かりやすく解説。日常臨床で遭遇するほぼ全ての症状・疾患から薬剤・検査情報まで瞬時に検索可能です。

まずは15日間無料トライアル
本サイトの知的財産権は全てエルゼビアまたはコンテンツのライセンサーに帰属します。私的利用及び別途規定されている場合を除き、本サイトの利用はいかなる許諾を与えるものでもありません。 本サイト、そのコンテンツ、製品およびサービスのご利用は、お客様ご自身の責任において行ってください。本サイトの利用に基づくいかなる損害についても、エルゼビアは一切の責任及び賠償義務を負いません。 また、本サイトの利用を以て、本サイト利用者は、本サイトの利用に基づき第三者に生じるいかなる損害についても、エルゼビアを免責することに合意したことになります。  本サイトを利用される医学・医療提供者は、独自の臨床的判断を行使するべきです。本サイト利用者の判断においてリスクを正当なものとして受け入れる用意がない限り、コンテンツにおいて提案されている検査または処置がなされるべきではありません。 医学の急速な進歩に鑑み、エルゼビアは、本サイト利用者が診断方法および投与量について、独自に検証を行うことを推奨いたします。

文献 

著者: A F LINCOLN, S E SIVERTSON
雑誌名: J Am Med Assoc. 1952 Sep 27;150(4):268-73.
Abstract/Text
PMID 14955436  J Am Med Assoc. 1952 Sep 27;150(4):268-73.
著者: T Solomon, R Kneen, N M Dung, V C Khanh, T T Thuy, D Q Ha, N P Day, A Nisalak, D W Vaughn, N J White
雑誌名: Lancet. 1998 Apr 11;351(9109):1094-7. doi: 10.1016/S0140-6736(97)07509-0.
Abstract/Text BACKGROUND: Acute flaccid paralysis remains common among Vietnamese children despite a pronounced fall in the incidence of poliomyelitis.
METHODS: During 1995, all 22 children presenting with acute flaccid paralysis to a referral centre in Ho Chi Minh City, Vietnam, had virological cultures and antibody measurements done on serum, cerebrospinal fluid, and faeces. A year later the children were reassessed and electrophysiological studies were done.
FINDINGS: Wild poliovirus type 1 was isolated from the faeces of only one patient, and non-polio enteroviruses from three patients. 12 (55%) of the 22 children with acute flaccid paralysis had evidence of acute Japanese encephalitis virus (JEV) infection, compared with only one (1%) of 88 age-matched hospital controls (children with diphtheria; p<0.0001). Compared with JEV-negative patients, weakness in JEV-infected children was more rapid in onset, tended to be asymmetrical, but was less likely to involve the arms. All 12 children with JEV infection were febrile at the onset of weakness, seven had acute retention of urine, and ten had CSF pleiocytosis. Seven of eight JEV-negative patients met the case-definition of Guillain-Barré syndrome, compared with only one of 12 JEV-positive children. At follow-up, patients with JEV infection had greater disability and were more likely to have muscle wasting than were JEV-negative children. Nerve conduction and electromyographic studies indicated damage to the anterior horn cells.
INTERPRETATION: JEV causes an acute flaccid paralysis in children that has similar clinical and pathological features to poliomyelitis. In endemic areas, children with acute flaccid paralysis should be investigated for evidence of JEV infection.

PMID 9660579  Lancet. 1998 Apr 11;351(9109):1094-7. doi: 10.1016/S014・・・
著者: Tom Solomon, Nguyen Minh Dung, Rachel Kneen, Le Thi Thu Thao, Mary Gainsborough, Ananda Nisalak, Nicholas P J Day, Fenella J Kirkham, David W Vaughn, Shelagh Smith, Nicholas J White
雑誌名: Brain. 2002 May;125(Pt 5):1084-93.
Abstract/Text Japanese encephalitis (JE) causes at least 10 000 deaths each year. Death is presumed to result from infection, dysfunction and destruction of neurons. There is no antiviral treatment. Seizures and raised intracranial pressure (ICP) are potentially treatable complications, but their importance in the pathophysiology of JE is unknown. Between 1994 and 1997 we prospectively studied patients with suspected CNS infections referred to an infectious disease referral hospital in Ho Chi Minh City, Vietnam. We diagnosed Japanese encephalitis virus (JEV), using antibody detection, culture of serum and CSF, and immunohistochemistry of autopsy material. We observed patients for seizures and clinical signs of brainstem herniation, measured CSF opening pressures (OP) and, on a subset of patients, performed EEGs. Of 555 patients with suspected CNS infections, 144 (26%) were infected with JEV (134 children and 10 adults). Seventeen (12%) patients died and 33 (23%) had severe sequelae. Of the 40 patients with witnessed seizures, 24 (62%) died or had severe sequelae, compared with 26 (14%) of 104 with no witnessed seizures [odds ratio (OR) 4.50, 95% confidence interval (CI) 1.94-10.52, P < 0.0001]. Patients in status epilepticus (n = 25), including 15 with subtle motor seizures, were more likely to die than those with other seizures (P = 0.003). Patients with seizures were more likely to have an elevated CSF OP (P = 0.033) and to develop brainstem signs compatible with herniation syndromes (P < 0.0001). Of 11 patients with CSF OP > or =25 cm, five (46%) died, compared with seven (9%) of 80 patients with lower pressures [OR 8.69, 95% CI 1.73-45.39, P = 0.005). Of the 50 patients with a poor outcome, 35 (70%) had signs compatible with herniation syndromes (including 19 with signs of rostro-caudal progression), compared with nine (10%) of those with better outcomes (P < 0.0001). Of 11 patients with CSF OP > or =25 cm, five (46%) died, compared with seven (9%) of 80 patients with lower pressures (OR 8.69, 95% CI 1.73-45.39, P = 0.005). The combination of coma, multiple seizures, brainstem signs and illness for 7 or more days was an accurate predictor of outcome, correctly identifying 42 (84%) of 50 patients with a poor outcome and 82 (87%) of 94 with a better outcome. These findings suggest that in JE, seizures and raised ICP may be important causes of death. The outcome may be improved by measures aimed at controlling these secondary complications.

PMID 11960897  Brain. 2002 May;125(Pt 5):1084-93.
著者: N M Dung, Lance Turtle, W K Chong, N T Mai, T T Thao, T T Thuy, R Kneen, N H Phu, B Wills, J Farrar, K Das, Tom Solomon
雑誌名: J Neurol. 2009 Dec;256(12):2052-60. doi: 10.1007/s00415-009-5249-5.
Abstract/Text Japanese encephalitis virus (JEV) is estimated to cause 30–50,000 cases of encephalitis every year. The disease occurs mainly in rural Asia and is transmitted to humans from birds and pigs by mosquitoes of the genus Culex. JE is diagnosed with antibody testing of the serum and CSF, but this is not available in many hospitals. Neuroimaging abnormalities, particularly thalamic hypodensity on computed tomography (CT) and hyperintensity on T2 weighted magnetic resonance imaging (MRI) have been described in case studies, but their usefulness for diagnosing JE is not known. We have therefore evaluated the usefulness of neuroimaging (CT and MRI) for the diagnosis of JE. The findings of thalamic lesions were compared with the final serological diagnosis in a cohort of 75 patients (children and adults) with suspected CNS infections in Southern Vietnam, a JEV endemic area. Thalamic lesions on CT and/or MRI combined had sensitivity 23% (95% confidence interval 12.9–33.1%), specificity 100%, positive predictive value 100% and negative predictive value 42.1% (95% confidence interval 30.2–53.8%) for a diagnosis of JE in this cohort. Over time, the thalamic lesions resolved in some patients. One patient showed disappearance of lesions on CT followed by reappearance of the lesions some time later, known as the fogging effect. In this setting, the presence of thalamic abnormalities suggested the diagnosis of JE, but their absence did not exclude it.

PMID 19633907  J Neurol. 2009 Dec;256(12):2052-60. doi: 10.1007/s00415・・・
著者: Penny Lewthwaite, M Veera Shankar, Phaik-Hooi Tio, Janet Daly, Anna Last, R Ravikumar, Anita Desai, V Ravi, Jane M Cardosa, Tom Solomon
雑誌名: Trop Med Int Health. 2010 Jul;15(7):811-8. doi: 10.1111/j.1365-3156.2010.02537.x. Epub 2010 May 11.
Abstract/Text OBJECTIVE: To compare two commercially available kits, Japanese Encephalitis-Dengue IgM Combo ELISA (Panbio Diagnostics) and JEV-CheX IgM capture ELISA (XCyton Diagnostics Limited), to a reference standard (Universiti Malaysia Sarawak - Venture Technologies VT ELISA).
METHODS: Samples were obtained from 172/192 children presenting to a site in rural India with acute encephalitis syndrome.
RESULTS: Using the reference VT ELISA, infection with Japanese encephalitis virus (JEV) was confirmed in 44 (26%) patients, with central nervous system infection confirmed in 27 of these; seven patients were dengue seropositive. Of the 121 remaining patients, 37 (31%) were JEV negative and 84 (69%) were JEV unknown because timing of the last sample tested was <10 day of illness or unknown. For patient classification with XCyton, using cerebrospinal fluid alone (the recommended sample), sensitivity was 77.8% (59.2-89.4) with specificity of 97.3% (90.6-99.2). For Panbio ELISA, using serum alone (the recommended sample), sensitivity was 72.5% (57.2-83.9) with specificity of 97.5% (92.8-99.1). Using all available samples for patient classification, sensitivity and specificity were 63.6% (95% CI: 48.9-76.2) and 98.4% (94.5-99.6), respectively, for XCyton ELISA and 75.0% (59.3-85.4) and 97.7% (93.3-99.2) for Panbio ELISA.
CONCLUSION: The two commercially available ELISAs had reasonable sensitivities and excellent specificities for diagnosing JEV.

PMID 20487425  Trop Med Int Health. 2010 Jul;15(7):811-8. doi: 10.1111・・・
著者: Sumalee Chanama, Walailuk Sukprasert, Areerat Sa-ngasang, Atchareeya A-nuegoonpipat, Somchai Sangkitporn, Ichiro Kurane, Surapee Anantapreecha
雑誌名: Jpn J Infect Dis. 2005 Oct;58(5):294-6.
Abstract/Text Detection of Japanese encephalitis virus (JEV)-specific IgM by IgM-capture enzymed-linked immunosorbent assay (IgM-capture ELISA) has been accepted as the standard for serological diagnosis. In the present study, we analyzed the time course of the positive rate of JEV-specific IgM in serum and cerebrospinal fluid (CSF) specimens from confirmed JE patients. Serum and CSF samples were obtained from 155 JE cases for diagnostic purposes at hospitals in Thailand from 2002 to 2004. The levels of specific IgM were assessed by IgM-capture ELISA in the 171 serum and 156 CSF samples. Anti-JEV IgM was detected in 26 of 44 serum samples collected on days 1-4 of the disease period, in 31 of 44 samples collected on days 5-8, in 23 of 26 samples collected on days 9-12, and in all the samples collected on day 13 or later. Specific IgM was detected in 60 of 66 CSF samples collected on days 1-4 of illness, and in all the CSF samples but one collected on day 7 or later. The results indicate that the detection of JEV-specific IgM in CSF by IgM-capture ELISA is a reliable laboratory diagnostic method for confirmation of JE throughout the disease period, while the detection of IgM in serum samples is a reliable method on day 9 or later.

PMID 16249624  Jpn J Infect Dis. 2005 Oct;58(5):294-6.
著者: Reena Swami, Radha Kanta Ratho, Baijayantimala Mishra, Mini P Singh
雑誌名: Scand J Infect Dis. 2008;40(10):815-20. doi: 10.1080/00365540802227102.
Abstract/Text The present study was carried out between July 2003 and December 2005 in PGIMER, Chandigarh, India and aimed to compare IgM capture ELISA and nested RT-PCR for the diagnosis of Japanese encephalitis (JE). The samples collected were cerebrospinal fluid and blood from 40 febrile patients with encephalitis (n=40, group I) and blood samples from febrile patients without encephalitis residing in JE endemic areas (n=45, group II). Overall, in CSF samples JE specific RNA was detected in 9/40 (22.5%), while 7/28 (25%) patients showed the presence of specific IgM antibodies. Only 28 CSF samples could be subjected to both RT-PCR and IgM and, among these, 13 cases were found to be confirmed JE based on IgM and/or RT-PCR positivity. Among the confirmed cases, 6 (6/13, 46.5%) could be detected by RT-PCR alone, 4 (4/13, 30.7%) by IgM capture ELISA and 3 (3/13, 23.1%) patients were positive by both the methods. All the RT-PCR positive cases had presented within 5 d of onset of illness. The serum samples of only 16 patients in group I could be tested for IgM antibodies and 5 (31.25%) were found to be positive, while in group II, 11.1% (5/45) positivity was observed. JE specific RNA could not be detected in serum samples of either group of patients. This study highlights the need for carrying out RT-PCR in CSF samples, compared to IgM antibody detection, for the early detection of JEV.

PMID 18618334  Scand J Infect Dis. 2008;40(10):815-20. doi: 10.1080/00・・・
著者: Usha Kant Misra, Jayantee Kalita
雑誌名: Prog Neurobiol. 2010 Jun;91(2):108-20. doi: 10.1016/j.pneurobio.2010.01.008. Epub 2010 Feb 2.
Abstract/Text Japanese encephalitis (JE) is one of the most important endemic encephalitis in the world especially in Eastern and Southeastern Asia. JE affects over 50,000 patients and results in 15,000 deaths annually. JE virus is a single stranded positive sense RNA virus belonging to family flaviviridae. JE virus is transmitted through a zoonotic cycle between mosquitoes, pigs and water birds. Humans are accidentally infected and are a dead end host because of low level and transient viremia. In the northern region, large epidemics occur during summers whereas in the southern region JE tends to be endemic: cases occur throughout the year with a peak in the rainy season. Occurrence of JE is more closely related to temperature than to humidity. JE is regarded as a disease of children in the endemic areas but in the newly invaded areas, it affects both the adults and children because of the absence of protective antibodies. For every patient of JE, there are large numbers of subclinical cases (25-1000). Symptomatic JEV infection manifests with nonspecific febrile illness, aseptic meningitis or encephalitis. Encephalitis manifests with altered sensorium, seizures and focal neurological deficit. Acute flaccid paralysis may occur due to anterior horn cell involvement. A wide variety of movement disorders especially transient Parkinsonian features and dystonia (limb, axial, orofacial) are reported in 20-60% patients. JE mainly affects thalamus, corpus striatum, brainstem and spinal cord as revealed by MRI and on autopsy studies. Coinfection of JE and cysticercosis occurs because of the important role of pigs in the life cycle of both JEV and cysticercosis. Laboratory diagnosis of JE is by IgM capture ELISA, which has high sensitivity and specificity. In the absence of specific antiviral therapy, JE is managed by symptomatic and supportive therapies and preventive measures. Purified formalin inactivated mouse brain derived vaccine and live attenuated vaccine (SA 14-14-2) are available; the latter is reported to be safe, effective and cheap. The role of Chimeric recombinant attenuated JE vaccine is under investigation. Control of JE is related to the wider issues of hygiene, environment, education and economy.

(c) 2010 Elsevier Ltd. All rights reserved.
PMID 20132860  Prog Neurobiol. 2010 Jun;91(2):108-20. doi: 10.1016/j.p・・・
著者: A Desai, V Ravi, S C Guru, S K Shankar, V G Kaliaperumal, A Chandramuki, M Gourie-Devi
雑誌名: J Neurol Sci. 1994 Mar;122(1):109-16.
Abstract/Text This study reports the detection of autoantibodies to myelin basic protein (MBP) and neurofilament proteins (NFP) in serum and cerebrospinal fluid (CSF) of Japanese encephalitis patients. The diagnosis of Japanese encephalitis was confirmed in 72 patients by the presence of virus specific antibodies to JEV in the CSF (28/72), viral antigen in the CSF (19/72) and simultaneous presence of both antigen and JEV antibodies in the CSF in 25/72 patients. Autoantibodies to either purified NFP (10) or MBP (8) or both (17) were detected in the CSF of 35 patients by ELISA in contrast with the control CSF samples. Amongst them 20 had similar antibodies in the serum as well. Correlation of immunological findings with the clinical outcome revealed that the presence of autoantibodies in the CSF especially to NFP was associated with a fatal outcome (P < 0.05).

PMID 7515105  J Neurol Sci. 1994 Mar;122(1):109-16.
著者: Mong How Ooi, Penny Lewthwaite, Boon Foo Lai, Anand Mohan, Daniela Clear, Lina Lim, Shekhar Krishnan, Teresa Preston, Chae Hee Chieng, Phaik Hooi Tio, See Chang Wong, Jane Cardosa, Tom Solomon
雑誌名: Clin Infect Dis. 2008 Aug 15;47(4):458-68. doi: 10.1086/590008.
Abstract/Text BACKGROUND: Japanese encephalitis is a major public health problem in Asia. However, there is little data on the long-term outcome of Japanese encephalitis survivors.
METHODS: We prospectively evaluated children with serologically confirmed Japanese encephalitis over an 8.3-year period. The patients were assessed and their outcomes were graded with a functional outcome score at hospital discharge and at follow-up appointments. We examined how patient outcome at hospital discharge compared with that at long-term follow-up visits, when changes in outcome occurred, and the prognostic indicators of the eventual outcome.
RESULTS: One hundred and eighteen patients were recruited into the study, and 10 (8%) died during the acute phase of illness. At hospital discharge, 44 (41%) of the 108 patients who survived had apparent full recovery; 3 (3%) had mild, 28 (26%) had moderate, and 33 (31%) had severe neurological sequelae. Eighty six of the 108 patients were followed up for a median duration of 52.9 months (range, 0.9-114.9 months). During follow-up, 31 patients experienced improvement, but 15 patients experienced deterioration in their outcome grade. In most cases, assessment during the first 3-6 months after hospital discharge was predictive of the long-term outcome. More than one-half of the patients continued to experience neuropsychological sequelae and behavioral disorders. A combination of poor perfusion, Glasgow coma score < or =8, and > or =2 witnessed seizures predicted a poor long-term outcome with 65% sensitivity and 92% specificity.
CONCLUSIONS: Neurological assessment of Japanese encephalitis survivors at hospital discharge does not predict long-term outcome. Seizures and shock are treatable risk factors for a poor outcome at hospital discharge and at long-term follow-up visits.

PMID 18616397  Clin Infect Dis. 2008 Aug 15;47(4):458-68. doi: 10.1086・・・
著者: R Kumar, A Mathur, K B Singh, P Sitholey, M Prasad, R Shukla, S P Agarwal, J Arockiasamy
雑誌名: Indian J Med Res. 1993 Jan;97:9-13.
Abstract/Text Over a five and a half year period, virological investigations for Japanese encephalitis (JE) were conducted in children admitted with acute encephalitis like illness to a large city hospital. The diagnosis of Japanese encephalitis was made by viral isolation from cerebrospinal fluid and/or a four-fold or higher rise in haemagglutination inhibiting antibodies in paired sera followed by demonstration of specific IgM antibodies by HI test after treatment with 2-mercapto ethanol. All children surviving the illness were contacted by post and followed up for sequelae. A total of 55 children could be followed up after 12-18 months and 22 of these even after 2 yr. A high rate of major sequelae (45.5%) in the form of frank motor deficits (32.7%), mental retardation (21.8%) and/or convulsions (18.2%) was observed. Neurological deficits were of diverse types and improved even after 2 yr of the illness. Fourteen patients (25.4%) had only minor deficits in the form of scholastic backwardness, behavioural problems and/or subtle neurological signs. Only 16 (29.2%) patients were completely normal on follow up. JE may therefore be an important cause of neurological handicap in this area. Sequelae of the disease were more severe if the initial illness was prolonged (P < 0.001, CI 2.45, 12.64), or associated with focal neurological deficits (P < 0.001, CI 1.97, 7.02).

PMID 8387460  Indian J Med Res. 1993 Jan;97:9-13.

ページ上部に戻る

戻る

さらなるご利用にはご登録が必要です。

こちらよりご契約または優待日間無料トライアルお申込みをお願いします。

(※トライアルご登録は1名様につき、一度となります)


ご契約の場合はご招待された方だけのご優待特典があります。

以下の優待コードを入力いただくと、

契約期間が通常12ヵ月のところ、14ヵ月ご利用いただけます。

優待コード: (利用期限:まで)

ご契約はこちらから