最新のNEJMは皮膚病変（小生のトラウマの病気）

最新のNEJMのイメージを見て、若干寒気がした。マラコプラキアという病名は小生の学生時代の病理の試験を思い出させる。学生のころ学部二年目の病理というのは学部一年目の生化学・生理とともに基礎医学の最大の鬼門であった。この病理で何人留年していったことだろうか。小生は授業の出席率が最低に近かったから試験は大変だったが、病理の試験で「マラコプラキア」について述べよという問題には困惑した。まったく知らない病気だったからだ。

今でもその名を覚えているマラコプラキアに今朝出会ったというわけだ。ぞくぞくする。

A 53-year-old man who had undergone both liver and kidney transplantation within the previous 2 years presented to the infectious diseases clinic with a 4-month history of progressively enlarging, painless nodules on his scalp (Panel A) and perianal region. He otherwise felt well. The immunosuppressive medications that he was receiving included tacrolimus, mycophenolate mofetil, and prednisolone. Four weeks before the development of the skin lesions, he had received pulse methylprednisolone for acute cellular rejection of the transplanted kidney. Biopsy of the lesions identified Michaelis–Gutmann bodies (basophilic inclusions) (Panel B, arrow), and cultures grew Escherichia coli and Pseudomonas aeruginosa. A diagnosis of malakoplakia was made. This rare chronic granulomatous condition, which occurs most frequently in immunocompromised patients, is thought to be due to defective intracellular killing of bacteria. It is characterized by focal inflammatory lesions with Michaelis–Gutmann bodies within macrophages. Cutaneous involvement is rare; the more typical presentation involves the kidney or bladder. Management combines prolonged antibiotic therapy, immunosuppression reduction, and sometimes surgical excision. The patient was treated with antibiotics, including ciprofloxacin, along with a concurrent reduction in immunosuppression. After 6 months of treatment, the lesions regressed, with some residual scarring.

Thomas Gliddon, M.B., B.S.
Kate Proudmore, M.B., B.S.
Sir Charles Gairdner Hospital, Nedlands, WA, Australia 
kate.proudmore@health.wa.gov.au