症例報告 Case Report

急性呼吸障害を来した単純ヘルペス脳炎 A case of an 89-year-old male with

pathologically confirmed brainstem
において脳幹病変が病理学的に確認でき lesion in herpes simplex encephalitis with
た 89 歳男性の 1 例 acute respiratory disorder

林 友豊 1)* Yuto Hayashi1)*

荒木 克哉 1) Katsuya Araki1)

井上 貴美子 2) Kimiko Inou2)

安藤 紘花 3) Hiroka Ando3)

藤村 晴俊 2) Harutoshi Fujimura2)

巽 千賀夫 1) Chikao Tatsumi1)

(臨床神経 2020;00:000-000) (Clinical Neurology 2020; 00: 000-000)

Key words：単純ヘルペス脳炎，脳幹脳炎，高齢者，呼吸不全 Key words: Herpes simplex encephalitis, brain stem encephalitis,
elderly, respiratory failure

はじめに Introduction

単純ヘルペス脳炎(herpes simplex encephalitis，以下 HSE と略記) Herpes simplex encephalitis (hereinafter abbreviated as “HSE”)
often manifests with fever, headache, and upper respiratory tract
は発熱や頭痛，上気道感染症状で発症し，意識障害，痙攣など infection symptoms and results in various brain dysfunctions such as
多彩な脳機能障害を来すことが多い。死亡率は 10～15%と高く，社 impaired consciousness and convulsions. Mortality is high, at 10 to
15%, and it is said that about half of patients are able to return to
会復帰可能な患者は約半数とされる 1)。今回我々は発熱と意識障 society.1) We experienced a case of HSE in an elderly man who
害に加え，急性呼吸障害を呈した高齢男性において，病理学的に脳 presented with acute respiratory disorder in addition to fever and
impaired consciousness in which brainstem lesions were confirmed
幹病変を確認しえた HSE 症例を経験したため報告する。 pathologically. Our report is presented below.

症例 Case
症例：89 歳，男性 Subject: An 89-year-old man

主訴：発熱，意識障害 Chief complaints: Fever, impaired consciousness

既往歴：慢性心不全，大腸憩室炎，陳旧性肺結核，アルツハイマ Past medical history: Cardiac failure chronic, diverticulitis of large

intestine, old pulmonary tuberculosis, dementia Alzheimer’s type.
ー型認知症。

家族歴：特記すべきことなし。 Family history: Nothing noteworthy.

現病歴：2018 年 3 月上旬より全身性の浮腫が出現し，心不全疑い History of present illness: In early March 2018, systemic oedema
appeared, and oral administration of furosemide was started due to
としてフロセミドの内服が開始となった。3 月中旬ごろより 38°C の発熱 suspected cardiac failure. From mid-March, a fever of 38°C
が持続し，発熱 4 日目に当院救急外来を受診した。血液検査で炎 persisted, and the patient visited the emergency outpatient
department of our hospital on Day 4 of fever. Blood tests showed no
症反応の上昇なく，胸部単純 X 線写真で肺炎像や胸水を認めず， increase in inflammatory reaction, and no pneumonia or pleural
気管支炎などを疑われ抗菌薬を処方され帰宅したが，翌日も発熱が effusion was observed on plain chest X-ray. Bronchitis, etc. was
suspected, and the patient was prescribed antibiotics and discharged
持続し意識障害も出現したため当院救急外来を再受診し緊急入院と to his home. However, fever persisted on the following day and
なった。 impaired consciousness also occurred, so the patient was re-
examined at the emergency outpatient department of our hospital and
was hospitalised on an emergency basis.

一般理学所見：体温 38.1°C ，血圧 154/88 mmHg ，脈拍 82/分・ General physical findings: Body temperature: 38.1°C, blood pressure
154/88 mmHg, pulse rate: 82/min, regular, oxygen saturation: 95%
整，酸素飽和度 95%(室内気)，胸部聴診で呼吸音清，副雑音な (room air), in chest auscultation, breath sounds were clear and there
し，心音純，収縮期雑音あり(Levine III/VI)。腹部に異常所見な was no accessory murmur. Heart sounds were pure, and there was
systolic bruit (Levine III/VI). There were no abnormal findings in
く，下腿浮腫認めず。皮膚乾燥が強かった。 the abdomen, and no lower leg oedema was observed. There was
severe dry skin.

神経学的所見：意識状態は JCS 10，GCS E3V3 M4 であり，明ら Neurological findings: The level of consciousness was JCS 10 and
GCS E3V3 M4, and no clear nuchal rigidity was observed. No
かな項部硬直は認めなかった。失語や精神症状は認めなかった。瞳孔 speech loss or psychiatric symptoms were observed. The pupils were
は正円同大で対光反射は両側迅速であり，四肢に運動麻痺，感覚 the same size, and the light reflex was rapid on both sides, and no
motor paralysis or sensory disturbance was observed in the limbs.
障害は認めなかった。

検査所見：一般血液検査では白血球数 4,700/mm3 ，CRP 0.08 Laboratory findings: General blood tests showed a white blood cell
count of 4,700/mm3 and CRP of 0.08 mg/dl, showing no
mg/dl と炎症所見を認めず，Na 125 mEq/l と低値であった。その他意 inflammatory findings, and sodium was low at 125 mEq/l. Among
識障害の原因となる肝臓や腎臓の機能異常は認めず，血糖は低下 the other results, there was no liver or kidney function abnormality
that would cause impaired consciousness, and the blood glucose
していなかった。抗核抗体，ビタミン B1 は正常範囲内であった。頭部 level was not decreased. Antinuclear antibodies and vitamin B1 were
単純 CT で右前頭部に少量の硬膜下血腫を認めたが，脳実質に病 within the normal range. Unenhanced head CT scan showed a small
amount of subdural haematoma in the right frontal region, but no
変は認めなかった。胸腹部単純 CT では明らかな異常を指摘できなか lesions were observed in the brain parenchyma. No clear
った。 abnormalities were noted on the unenhanced thoracoabdominal CT
scan.

入院後経過：入院時，発熱，意識障害を認め，脱水症および肺 Clinical course after admission: Upon admission, fever and impaired
consciousness were observed, and dehydration and infectious disease
炎などの感染症が疑われた。入院前に開始されたフロセミドによる低 such as pneumonia were suspected. It was considered possible that
the impaired consciousness had occurred due to hyponatraemia
Na 血症によって意識障害が出現した可能性が考えられたため，補液 induced by furosemide, which was started before the hospitalisation,
so sodium was corrected with fluid replacement. With regard to the
による Na の是正を行った。発熱に関しては画像上明らかな感染巣を fever, no clear infection focus could be pointed out on imaging, and
指摘することができず，腫瘍熱や膠原病なども鑑別に挙がったため各 tumour associated fever and collagen disorder were also suggested
for differentiation, so various tests were performed, but no
種検査を行ったが有意な異常所見は得られなかった。 significant abnormal findings were obtained.

*Corresponding author: 市立豊中病院神経内科〔〒560-8565 大阪府豊 *Corresponding author: Department of Neurology, Toyonaka Municipal
Hospital (4-14-1 Shibahara-cho, Toyonaka-shi, Osaka-fu 〒560-8565)
中市柴原町 4 丁目 14 番 1 号〕

1
1)
市立豊中病院神経内科 : Department of Neurology, Toyonaka Municipal Hospital

2
2)
国立病院機構大阪刀根山医療センター脳神経内科 : Department of Neurology, National Hospital Organization Osaka
Toneyama Medical Center

3
3)
市立豊中病院病理診断科 : Department of Pathology, Toyonaka Municipal Hospital

第 2 病日に撮像された頭部単純 MRI では両側帯状回皮質に拡散 Unenhanced head MRI performed on Day 2 of illness showed high
signal intensity on diffusion-weighted images and FLAIR images in
強調画像および FLAIR 画像で高信号を認めた(Fig.1A, B)。頭部画 the bilateral cingulate cortex (Fig. 1A, B). In cranial imaging,
像検査では脳実質内の出血は確認できなかった。脳脊髄液検査では haemorrhage in the brain parenchyma could not be confirmed.
Cerebrospinal fluid analysis revealed a starting pressure of
初圧 5 cmH2O，外観は無色透明で細胞数は 2/mm3(単核球 5 cm H2O, a colourless transparent appearance, cell count of 2/mm3
100%)，糖 63 mg/dl(同時血糖 112 mg/dl)であった。脳脊髄液の細 (100% mononuclear cells), and glucose of 63 mg/dl (simultaneous
blood glucose: 112 mg/dl). The bacteriological examination of
菌学的検査では異常を認めなかった。脳脊髄液は初圧が低く 2 ml 程 cerebrospinal fluid showed no abnormalities. Due to low initial
度しか採取できなかったが，硬膜下血腫があることから過度な採取は pressure, only about 2 ml of cerebrospinal fluid could be collected,
but given the presence of subdural haematoma, it was judged that
危険と判断し，脳脊髄液の単純ヘルペスウイルス(herpes simplex excessive collection would be dangerous, so the herpes simplex virus
virus，以下 HSV と略記)-DNA 検査は実施できなかった。補液を中 (hereinafter abbreviated as “HSV”)-DNA testing of the cerebrospinal
fluid could not be performed. There was temporary improvement of
心とした初期治療により意識状態の一時的な改善を認めたものの， the level of consciousness due to initial treatment mainly with fluid
JCS 3 から 20 程度で推移し，血清 Na 値が基準値内となっても意識 replacement, but it remained around JCS 3 to 20, and even when the
serum sodium level returned to within the reference range, sufficient
状態の十分な改善は得られなかった。脳波検査では高振幅徐波を認 improvement in the level of consciousness was not achieved. High
めたが，明らかなてんかん原性脳波や周期性一側てんかん型放電は voltage slow wave was observed on electroencephalogram, but no
clear epileptogenic brain waves or periodic lateralised epileptiform
見られなかった。第 4 病日より酸素化不良が見られ，意識障害に伴う discharges were observed. From Day 4 of illness, poor oxygenation
誤嚥性肺炎の合併が示唆されたため，アンピシリン・スルバクタム was observed, suggesting a complication of pneumonia aspiration
associated with impaired consciousness, so administration of
(ampicillin/sulbactam，以下 ABPC/SBT と略記) 6 g/day の投与を ampicillin/sulbactam (hereinafter abbreviated as “ABPC/SBT”)
開始した。第 5 病日に血清の抗 HSV IgM 抗体および抗 HSV IgG 6 g/day was started. On Day 5 of illness, the patient was found to be
positive for anti-HSV IgM and anti-HSV IgG antibodies in serum.
抗体が陽性であることが判明した。意識障害と発熱の経過から HSE Considering the possibility of HSE based on the course of impaired
の可能性を考え，アシクロビル(acyclovir，以下 ACV と略記)1,500 consciousness and fever, administration of aciclovir (hereafter
abbreviated as “ACV”) 1,500 mg/day was started. In the contrast-
mg/day の投与を開始した。第 6 病日の頭部造影 MRI では拡散強調 enhanced head MRI on Day 6 of illness, the bilateral cingulate
画像の両側帯状回皮質病変が拡大し，両側側頭葉内側にも cortex lesions in diffusion-weighted images enlarged, and FLAIR
high signal intensity lesions appeared on the medial sides of the
FLAIR 高信号の病変が出現したが，脳幹には病変を認めなかった bilateral temporal lobes, but no lesions were observed in the
(Fig.1C, D)。ガドリニウム造影 MRI ではいずれの病変も造影効果を示 brainstem (Fig. 1C, D). Gadolinium-enhanced MRI showed no
contrast effect in any of the lesions. A thoracoabdominal contrast-
さなかった。第 7 病日に撮像した胸腹部造影 CT では両肺に誤嚥性 enhanced CT performed on Day 7 of illness showed pneumonia
肺炎像を認めたが，背側に限局し，広範囲な病変は認めなかった。 aspiration in both lungs, but it was localised to the dorsal side, and
extensive lesions were not observed. Treatment with antibiotics and
抗生剤と抗ウイルス薬の治療を継続したが意識状態は徐々に悪化 antiviral drugs was continued, but the patient’s level of
し，第 8 病日の朝には JCS 300 となった。その後失調性呼吸となり， consciousness gradually worsened, and in the morning of Day 8 of
illness, it was JCS 300. Subsequently, the patient developed ataxic
breathing and died at night on the same day. With consent from the
同日夜に死亡した。ご家族の同意を得て死亡 11 時間 30 分後より病 family, a pathological autopsy was performed at 11 hours and 30
minutes after death.
理解剖を行った。

一般病理所見：気管支内には肉眼的に消化管内容物と同様の物 General pathology findings: In the bronchi, macroscopically, there

was retention of substances similar to the contents of the
質が貯留しており，顕微鏡的にも活動性の炎症を伴った肺炎像が広 gastrointestinal tract, and microscopically, pneumonia with active
範囲に認められた。急性期の誤嚥性肺炎の像であり，右肺上葉に陳 inflammation was observed over an extensive area. This was an
image of pneumonia aspiration in the acute phase, and old pleural
旧性の胸膜肥厚を伴っていた。心臓には加齢性の変化はみられるもの thickening was observed in the upper lobe of the right lung.
の弁膜症や心肥大，線維化などは認めなかった。結腸の肉眼的観察 Although age-related changes were observed in the heart, conditions
such as valvular disease, cardiac hypertrophy, and fibrosis were not
では憩室は指摘し得なかった。 observed. No diverticulum could be noted on macroscopic
observation of the colon.

神経病理学的所見：固定後脳重 1,430 g。肉眼的には外観上前頭 Neuropathological findings: Brain weight after fixation was 1,430 g.
Macroscopically, mild atrophy was observed in the frontal lobe
葉脳回の軽度萎縮を認めた。割面では両側帯状回，海馬・扁桃体を gyrus. On the cut surface, softening of the bilateral cingulate gyrus,
含む側頭葉内側部，第 3 脳室周囲の視床と視床下部に軟化を認 the medial temporal lobe including the hippocampus and amygdala,
and the thalamus and hypothalamus around the third ventricle was
め，病巣部の皮質および皮質下白質は変色し皮髄境界は不明瞭で observed, and the cortical and subcortical white matter of the lesion
あった。右海馬 CA1 領域に点状出血を認めた。小脳及び脳幹部には were discoloured and the corticomedullary border was unclear.
Petechiae were observed in the right hippocampal CA1 region. No
肉眼的に明らかな異常を指摘できなかった(Fig.2)。光顕的にテント上の macroscopically clear abnormalities were noted in the cerebellum or
肉眼的軟化巣は皮質の浮腫と神経細胞の脱落を伴う壊死性病変で brainstem (Fig. 2). In microscopic examination, the supratentorial
sites with macroscopic softening were necrotic lesions with cortical
あり，単核球主体の perivascular cuffing を認め，一部に出血を伴っ oedema and neuronal loss, and perivascular cuffing was observed
ていた(Fig.3A)。 mainly in mononuclear cells, with some bleeding (Fig. 3A).

脳幹小脳に壊死性病変は認められなかった。脳幹部では広範囲に血 No necrotic lesions were observed in the brainstem or cerebellum. In

the brain stem, extensive extravascular inflammatory mononuclear
管外への炎症性単核球浸潤とグリア結節の出現を認めた(Fig.3B)。 cell infiltration and appearance of glial nodules were observed (Fig.
HE 染色による観察でごく少数の Cowdry A 型好酸性核内封入体 3B). On HE staining observation there was a very small number of
Cowdry type A eosinophilic nuclear inclusion in glial nuclei of the
を，延髄網様体のグリア核内に認めた(Fig.4B)。HSV-1 免疫染色 bulbar reticular formation (Fig. 4B). In HSV-1 immunostaining
(anti-HSV1 polyclonal antibody, bs-8505R, Bioss, USA)にてテント上 (anti-HSV1 polyclonal antibody, bs-8505R, Bioss, USA), no nerve
tissue was stained in the supratentorial lesions, and positive findings
病変の神経組織は染色されず，脳幹の一部の神経細胞とグリアの細 were observed in the cytoplasm of some nerve cells and glial cells of
胞質に陽性所見を認めた(Fig.4D)。延髄において HSV-1 陽性細胞は the brainstem (Fig. 4D). In the medulla oblongata, HSV-1 positive
cells were sporadically observed in the raphe nuclei, reticular
縫線核，網様体と三叉神経脊髄路核に散見され，舌下神経核にも formation, and spinal tract nucleus of trigeminal nerve, and a small
少数認められた。電子顕微鏡によるウイルスの観察は行わなかった。そ number were also observed in hypoglossal nerve nuclei. Observation
of viruses with electron microscopy was not performed. Other
の他の所見として大脳皮質及び基底核に老人斑を認め(Braak stage findings included senile plaques in the cerebral cortex and basal
C，Thal phase 3)，辺縁系から新皮質にかけて神経原線維変化が認 ganglia (Braak stage C, Thal phase 3), and neurofibrillary tangles
were observed from the limbic system to the neocortex (Braak stage
められた(Braak stage IV)(NIA-AA guideline; A2B2C2)。また剖検時 IV) (NIA-AA guideline; A2B2C2). HSV-DNA positive was
に採取した脳脊髄液検体から HSV-DNA 陽性を確認した。 confirmed in the cerebrospinal fluid sample collected at the time of
necropsy.

考察 Discussion

本症例は急性呼吸障害で死亡した高齢男性の HSE の症例であり， This is a case of an elderly man with HSE who died due to acute
respiratory disorder, in which we were able to pathologically
病理学的に呼吸障害の原因と思われる脳幹部病変を確認し得た症 confirm brainstem lesions, which were considered to be the cause of
例である。 the respiratory disorder.

HSE では側頭葉内側の病変が典型的とされるが，10～30%で側頭 In HSE, lesions in the medial temporal lobe are considered to be
typical, but in 10 to 30% of cases, there are lesions in areas other
葉以外にも病変を認める 2)3)。HSE による脳幹脳炎 24 例の報告で than the temporal lobe.2)3) Among 24 case reports of encephalitis
は，脳幹に限局した症例は 29%，脳幹以外にも病変を認めた症例 brain stem due to HSE, lesions were localised to the brainstem in
29% of cases, and there were also lesions in areas other than the
は 71%であった。死亡率は 41%であったが，ACV 治療例では 22%で brainstem in 71% of cases. The mortality rate was 41%, but among
あった 4)。 the patients treated with ACV, it was 22%.4)

榊原らの報告では側頭葉型 40%，側頭脳幹型 20%，脳幹型 23% In a report by Sakakibara et al., the temporal lobe type makes up
40% of cases, the temporal and brainstem type makes up 20%, and
とされており，脳幹型は死亡や再発を認めず予後良好とされる 5)。本 the brainstem type makes up 23%, and the brainstem type is said to
症例では病理学的に脳幹病変を確認できたが，HSE の脳幹病変の have favourable prognosis, with no death or recurrence observed. 5)
Brainstem lesions were pathologically confirmed in this case, but
病理学的症例報告は少なく，我々が知り得た限りでは数例のみであ there have been few pathological case reports of brainstem lesions in
る 6)7)。また，脳幹に限局した HSE の剖検例は過去に 3 例が報告され HSE, and as far as we could find, there have only been a few
cases.6)7) In addition, three cases of autopsy of HSE localised to the
ている 8)～10)。 brainstem have been reported in the past.8)-10)

脳幹脳炎においては急性期に高度呼吸障害を呈するが，回復期に呼 In encephalitis brain stem, severe respiratory disorder occurs during

the acute phase, but respiratory failure can occur during the recovery
吸不全を来すこともあり，これらの呼吸不全は橋や延髄，上位頸髄 phase, and these respiratory failures are due to disorders of the pons,
などの障害による 11)12)。脳幹型 HSE における呼吸障害に関しては， medulla oblongata, upper cervical spinal cord, and the like. 11)12) With
regard to respiratory disorders in brainstem HSE, a case has been
失調性呼吸を呈し剖検で脳幹病変が主座であることを示した症例が reported in which ataxic breathing was exhibited, and autopsy
報告されている 13)。脳幹型は予後が良いという報告がある一方で，高 showed that the brainstem lesion was the primary site. 13) While it has
been reported that the brainstem type has a favourable prognosis,
度の呼吸障害により人工呼吸管理を要する症例もあることから注意が caution is necessary because some cases require artificial respiratory
必要である 14)。 management due to severe respiratory disorder.14)

本症例の呼吸障害の原因として脳幹病変の他に誤嚥性肺炎の合併 In terms of the cause of the respiratory disorder in this case, in

addition to the brainstem lesions, the complication of pneumonia
も寄与したと考えられる。死亡前日の CT で高度な肺炎像はなく，失 aspiration is also considered to have contributed. There was no
調性呼吸を呈したことなどから誤嚥性肺炎のみでは急速に進行する呼 image of severe pneumonia on CT on the day before death, and due
to the fact that there was ataxic breathing and other considerations, it
吸障害を説明することは困難であった。ICU へ入室する HSE のうち was difficult to explain the rapidly progressing respiratory disorder
29%が誤嚥性肺炎を合併しているという報告があるものの，合併その as being caused by pneumonia aspiration alone. Although it has been
reported that 29% of cases of HSE admitted to ICU have pneumonia
ものは予後に直接関与しない 15)。インフルエンザウイルス感染症では， aspiration as a complication, the complication itself is not directly
ウイルスによる脳幹の炎症が嚥下障害を引き起こし，結果的に誤嚥性 involved in the prognosis.15) It has been reported that in influenza
virus infections, inflammation of the brainstem due to the virus
肺炎が生じると報告されており 16)，本症例においても同様の機序が推 causes dysphagia, resulting in pneumonia aspiration,16 and a similar
定される。 mechanism is inferred in this case.

本症例の脳内病変は程度の差より，帯状回や海馬などから橋，延 Based on the differences in the extent of the brain lesions in this
case, it was thought that the lesions spread from the cingulate gyrus
髄へ進展したものと考えられた。脳幹への炎症が波及した結果として意 and hippocampus to the pons and medulla oblongata. It is thought
識障害，嚥下障害，中枢性呼吸障害が生じ，失調性呼吸および that as a result of the inflammation affecting the brainstem, impaired
consciousness, dysphagia, and central respiratory disorder occurred,
誤嚥性肺炎のために呼吸不全が急速に進行したと考えられる。 and the respiratory failure progressed rapidly due to ataxic breathing
and pneumonia aspiration.

また，本症例は 89 歳と高齢であった。近年 80 歳以上の HSE が増加 In addition, the subject was elderly, at 89 years of age. In recent
years, there has been an increase in HSE in patients aged 80 years or
しており，94 歳の症例も報告されている 17)。本症例の 89 歳は本邦報 older, and there has also been a report of a case of a 94-year-old
patient.17) The 89-year-old in this case is the oldest age among the
告例の中では最高齢である。高齢であることはそれ自体に加え，不十 cases reported in Japan. Advanced age itself is a poor prognosis
分な検査や脳脊髄液細胞上昇を認めないことなどが予後不良因子と factor and it also involves the poor prognosis factors of insufficient
tests and the absence of elevated cerebrospinal fluid cell count,
してあげられ，総じて治療の遅れにつながる 18)。HSE の予後不良例 leading to generally delayed treatment.18) Among the cases of HSE
で，初回の脳脊髄液細胞数が正常であった 81 歳女性例や初診時の with poor prognosis, there have been reports of an 81-year-old
woman whose initial cerebrospinal fluid cell count was normal and a
症状が倦怠感と食思不振のみであった 78 歳男性例も報告されてお 78-year-old man whose symptoms at the initial examination were
り，いずれも診断の遅れが指摘されている 19)20)。高齢者は若年者と比 only malaise and poor appetite, and a delay in diagnosis was pointed
out in both cases.19)20) Compared to young people, the elderly are
較して HSE に罹患しやすく，死亡率が高いうえ非典型的な症状が多 more susceptible to HSE, have higher mortality rates, and have many
く，注意が肝要である 21)22)。 atypical symptoms, so caution is essential.21)22)

HSE における脳脊髄液の細胞数については，本邦 108 例での検討で With regard to cell count in cerebrospinal fluid in HSE, it was
reported that in a study of 108 cases in Japan, 10% of the cases had a
は 10%の例で細胞数が 10/mm3 未満であったと報告されている 23)。本 cell count of less than 10/mm3.23) Cerebrospinal fluid analysis in this
症例の脳脊髄液検査においても細胞数 2/mm3 と上昇を認めなかっ case also showed a cell count of 2/mm3, and thus elevation was not
observed. Even among cases in which the initial cell count is within
た。初回の細胞数が正常範囲内の症例でも多くは経過に従って上昇 the normal range, the cell count increases during the course, but
するが，経過を通じて細胞数が上昇しない症例もある 24)。免疫正常 there are also cases in which the cell count does not increase at any
point during the course.24) It is necessary to keep in mind that
者では稀である 25)にせよ，細胞数増加を伴わない HSE が存在するこ although this is rare in immunocompetent people,25) there are cases
とを念頭に置く必要がある。 of HSE in which the cell count does not increase.

HSE は致死率が高く早期の診断と治療が重要となる疾患である。本 HSE is a disease with a high fatality rate and early diagnosis and
treatment are important. Respiratory disorder can progress rapidly
症例のように脳幹病変を来した場合は呼吸障害の急速な進行を認め when there are brainstem lesions, as in this case. The impaired
ることもある。本症例の意識障害は入院当初，低 Na 血症などによる consciousness in this case was initially considered to be due to
hyponatremia, etc. when the patient was admitted, and due to the fact
ものと考えられ，脳脊髄液検査で細胞数正常であったことから HSE の that cerebrospinal fluid analysis showed a normal cell count, the
可能性を十分に考慮できなかった。高齢者の発熱を伴う意識障害では possibility of HSE could not be sufficiently considered. In cases of
impaired consciousness accompanied by fever in elderly patients, it
電解質異常などを伴っている場合でも，常に HSE の可能性を考え， is important to always consider the possibility of HSE while
診療にあたることが重要である。 providing medical care, even if there are also electrolyte
abnormalities.

本報告の要旨は，第 112 回日本神経学会近畿地方会で発表し，会長推薦 The abstract of this report was presented at the 112nd Kinki Regional Meeting
of the Japanese Society of Neurology and was chosen as the chairman’s
演題に選ばれた。 recommended lecture.

謝辞：入院中の主担当医として本症例の診療に尽力いただきました現大阪大 Acknowledgments: We would like to express our deep gratitude to Dr

Takashi Miwa and Dr Hisashi Murata, currently at the Department of
学医学部附属病院脳神経内科三輪隆志先生および村田尚先生に深謝いた Neurology, Osaka University Hospital, for their tireless efforts in the
します。 treatment of this case as the primary attending physicians during
hospitalisation.

※著者全員に本論文に関連し，開示すべき COI 状態にある企業，組織，団 *There are no corporations, organisations, or groups for which COI must be
disclosed regarding this paper, for any of the authors.
体はいずれも有りません。