尿路結石と後腹膜リンパ節腫脹により両側水腎症を呈したサルコイドーシスの一例

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1 尿路結石と後腹膜リンパ節腫脹により両側水腎症を呈したサルコイドーシスの一例 要旨 ACE Ca, ACE, CT 30 mg Ca Cr CT 日サ会誌 2005;25:39-43 キーワード : A Case of Sarcoidosis Manifesting Bilateral Hydronephrosis due to Nephrolithiasis and Retroperitoneal Lymphadenopathy Koichi Yamamura, Tetsuya Adachi, Tomoko Yano, Hisanao Yoshihara, Shigeharu Ueki, Hiroyuki Tashimo, Hidenori Arai, Hiroyuki Nagase, Oji Obayashi, Mikio Nakajima, Ken Ohta ABSTRACT We report a case of a 42-year old man who had cervical and bilateral hilar lymphadenopathy with elevated serum ACE level diagnosed by a private physician in February He was referred to Teikyo University Hospital because of bilateral hydronephrosis in April 2004, and underwent nephrostomy followed by retrograde ureteral stent replacement. As the biopsy specimens from skin and lung revealed non-caseating epithelioid cell granuloma, the diagnosis of sarcoidosis was confirmed in reference to increased serum levels of calcium, angiotensin converting enzyme and lysozyme. The findings of abdominal computed tomography showed that right nephrolithiasis and left ureteral compression by retroperitoneal lymphadenopathy were responsible for bilateral hydronephrosis. Treatment with prednisolone after extracorporeal shock wave lithotripsy reduced serum calcium and creatinine levels accompanied with an improvement of lymphadenopathy and hydronephrosis. [JJSOG 2005;25:39-43] keywords ; Sarcoidosis, Hydronephrosis, Nephrolithiasis, Retroperitoneal lymphadenopathy 帝京大学医学部内科学講座呼吸器 アレルギー著者連絡先 : 足立哲也 東京都板橋区加賀 帝京大学医学部内科学講座 TEL: FAX: tadachi@med.teikyo-u.ac.jp Teikyo University School of Medicine Department of Internal Medicine Division of Respiratory Medicine and Allergy 39

2 日サ会誌 2005, 25(1) はじめに 1) Ca Table 1. Laboratory findings on admission 症例提示 症例 :42 主訴 : 既往歴 家族歴 : 喫煙歴 : 現病歴 : ACE 入院時現症 : / 144/ 82 mmhg 検査所見 : BUN 25.8 mg/dl Cr 2.3 mg/dl Ca/Cr 0.69 Ca ACE 11.0 mg/dl 42.3 IU 77.0 g/ml CRP 4.5 mg/dl Table 1 X Figure 1 Figure 2 CT Figure 3 Ga Figure 4 Figure 5 Figure 1. Chest X-ray showed bilateral hilar lymphadenopathy with pulmonary reticular shadow. 40

3 Figure 2. Abdominal ultrasonography examined on admission revealed dilated pelvis of both kidney (arrow). A B Figure 3. Abdominal CT scan on admission (a) revealed right nephrolithiasis (arrow), and (b) left retroperitoneal lymphadenopathy (arrowhead) accompanied with a compressed ureter (arrow). Figure 4. Multiple uptakes of gallium were found in supraclavicular, axillar, hilar, abdominal, inguinal and femoral lesions. 41

4 日サ会誌 2005, 25(1) A Figure 5. B Skin biopsy specimen showed non-caseating epithelioid cell granuloma. 臨床経過 : Cr Cr 30 mg Ca Cr Ca/Cr CT X Figure 6 Figure 6. Clinical course. 42

5 考察 Ca Göbel Ca Ca 2 Ca Ca 10-20% 2 D Bell 1,25-(OH) 2 D 3 Ca 3 1,25-(OH) 2 D 3 25-(OH) 2 D 3 4 1,25-(OH) 2 D 3 1 -hydroxylase 5 1 hydroxylase mrna Ca 6 1,25-(OH) 2 D 3 Ca 1,25-(OH) 2 D 3 Ca 1,25-(OH) 2 D 3 Ca 20% 2 Ca 29 GFR 20 ml/min 13 7 IgA Ca Ca/Cr Cr Ca Ca 1 Cr Ga 結論 引用文献 1) Hunningake GW, Costabel U, Ando M, et al: ATS/ERS/ WASOG statement on sarcoidosis. Sarcoidosis Vasc Diffuse Lung Dia 1999; 16: ) Gobel U, Kettritz R, Schneider W, et al: The protean face of renal sarcoidosis. J Am Soc Nephrol 2001; 12: ) Bell NH, Stern PH, Pantzer E et al: Evidence that increased circulating 25-dihydroxyvitamine D is the probable cause of abnormal calcium metabolism in sarcoidosis. J Clin Invest 1979; 64: ) Adams JS, Singer FR, Gacad MA et al: Isolation and structural identification of 1,25-dihydroxyvitamine D3 produced by cultured alveolar macrophages in sarcoidosis. J Clin Endocrinol Metab 1985; 60: ) Reichel H, Koeffler HP, Barbers R et al: Regulation of 1,25- dihydroxyvitamine D3 production by cultured alveolar macrophages from normal human donors and from patients with pulmonary sarcoidosis. J Clin Endocrinol Metab 1987; 65: ) Inui N, Murayama A, Sasaki S, et al: Correlation between 25-hydroxyvitamin D3 1α-hydroxylase gene expression in alveolar macrophages and the activity of sarcoidosis. Am J Med 2001; 110: ) Simonsen O, Thysell H: Sarcoidosis with normocalcemic granulomatous nephritis. Five case reports and a review of 24 cases in the literature. Nephron 1985; 40: ) Schoenfeld RH, Belville WD, Buck AS, et al: Unilateral ureteral obstruction secondary to sarcoidosis. Urology 1985; 25: ) Fraioli P, Montemurro L, Castrignano L, et al: Retroperitoneal involvement in sarcoidosis. Sarcoidosis 1990; 7: )Miyazaki E, Tsuda T, Mochizuki A et al: Sarcoidosis presenting as bilateral hydronephrosis. Intern Med 1996; 35:

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