090828 MAC
090828 MAC
日本で保険で認められているのはCAM・RFBのみ
他必要なのは、STFLX、EB
RFB、EB、CAMが国際的
3drugにしないと、48週で100%耐性になる
空洞のあるMACは、排菌のたびに違うMACがでる
(TBでもたまにあるが、MACは普通)
→4drugが一番いい
単剤は無意味
症例:
CRP 20、39度の発熱続く方
左肺がすべて空洞。下に肺炎あり。
4剤併用で、MAC陰性化
けれど、6か月以上の治療期間が必要だった。
●RFBとCAMの相互作用
CAMがRFBの血中濃度を上げる
→ ぶどう膜炎の副作用の発症頻度が高まる
●いつまで治療するのか?
4年以上は必要????
ガイドラインよりは長く必要そう
●早い段階で外科治療も念頭に置くべき
化学療法を開始して、散布病巣が消えてから外科療法、がありうる
気道構造の破壊があれば、外科を行うべき
●生存曲線
N=200
中間値:7300日
・女性に多い
・最近増加
・中葉舌区からはじまる
・in vivo, in vitro で耐性が違う
→耐性の結果と、治療効果が一致しないことは多い
■中葉舌区症候群
(質問)菌が同定されていないが、CAMで様子をみている
どうすべき?
→ (私は)EMを投与。400mg投与すると、MACがあったとき、CAM耐性を誘導しない。EM耐性は、CAM耐性とはかぶらない。
CAMを600使ってしまうと、将来MACがでたとき、耐性化している
■DLST(+)のときどうする?
→抗結核薬はアレルギー起きやすいが、DLST陽性でも必ずしもアレルギーでない…。減感作すれば、ほとんどつかえる
■経過はどう見る?
→細菌は必ずしもとれない。画像が最も大切。
→大きな空洞ある時は、まず内科的には無理。6か月の化学療法で、外科的手術の必要性はわかる
空洞病変あれば、化学療法をしても、新たに散布されてしまう
●何治例は、アスペルギルス症に移行している可能性がある
■CAMで下痢になるときどうする?
→腸の蠕動運動が更新することがCAMはある。腸内細菌叢は少ない? だから下痢というより、「何回もトイレに行く」が多い
…ブスコパンを使用
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