１２４１Ｍ瓦小ﾘIMM１級学会雑ii＆症例Ⅱ報 告著明な胆襄壁肥厚を呈したＡ型肝炎の１例’'''1部祥英，子安ゆうこ，北林lIiiil，波巡''参一郎’小lIlJn)安､|え，
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YoshihlsaA1〕e,YukoKoyasuTaeruKitabayashi,ShuichiroWatanabe,YasuheiOdaiima，KenjiSadamasul),TakayukiShinkail）

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AbS/'Ⅲ`ゾlWedcscribea9veal書01.上１１)aneseboywilbhep〔ltitisAAcutehepatitisAinourl〕a(ientwasAbsWzZclchal･actel･izedl)yjaundice,anincreaseinASTandAUr,ａｐ()silivGser()logictestIbrlhelgMantibodvto
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thepu(ativeVP1/2Ａwas、()tdel〔PctedandlheviralstrainwasclassiHedassubgenotyl〕elAWhileepidemicsoIhel〕atilisAhavenoI0ccunで(11℃centlyinJal)an,casesoIhcpalitisAarenol
inh℃qucn[.Ｗ(､ｓｈ()uldstilll)ａｙａＵ(nnli()11[()ｈｅl〕atitisA
ＦｍｗｌｊｏﾉYWv

HepaiiljSA,Genotype,Ｐｅｄｊａｌ/わcase,EPjde/77iq777/cke/7edgaﾉﾉb/adderwaﾉノ

lｎｔｒｏｄｕｃｔｉｏｎIIel)aIitisAvirus（HAV）isaII1ellll〕(勘】･()｢theＩｎａｖｌ)上，（､、ｌａｒｇｅ〔ｌ；ｅｖｅｎａｃｕ(GI)ａｎｃｒ(似ａｔｉｔｉｓｏｒｍｙ(〕cardilishasbeenrel〕〔)rted,allh()ughrarelv1I、

Picol･IIavirusfanlily・ＨＡＶｉｎｆｅｃｔｉ(〕１１ｓ（)ccur

ThissIudyrel〕ortsachildwilhhGpatilisA

throughouu1lGw()1．ｌｄｂｕｔａｒｏｍ(〕s（１）r()valenlinwh()scgalⅡ〕1adderwallwas１℃markably［hickeneddevclopingc(〕unlries､Inadditi()ｎt(〕lhclivel．,()ther〔1uril1gth(､aculel〕ｈａｓＧｏｆ(llcdis(凶asc、Ｗｅａｌｓ(）organsystcmscal11〕ｅａｆ[ectcdbyHAVinhcUon・inveBIigal(〕(１１hcHAVgenotypeinserumh-omtheForGxaml)le,rem〔〕I1allymphn()〔les〔llldlhesl〕leel1I)a[i(nnL

原脇受１，１１１：２()〔〕3〈1K12112011,11と終受１，１１１：2004イド３１１３０１１

別HIII1iIIi求光：YoshifusaAbeM.，.,I)el)〔lrlm(､nloIPedialrics,Ｓｈ()waUI1iversitySchoo1()[Ｍ(xlicil10
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ＯｎＭａｒｃｈ２２,2002,a9yeal毛oldJapanesel)()ywaslakenl)yhismotherI()aphysicianbecauso()iiever､Ｔｈｅｐａ(ientwasdiagnosedastonsillitis・Ｏｎ

Table１．Hematoloqicalvaluesonadmission
R()d-cellcountllemoRdobin

37.5％

Whilc-cellcount

5.8×103//A2

Dilkm･entialcountfeelingeasily［ired・Then，()nApril4,heatesushi

again・Ｔｈｅ〔layafLer,ｈｅ]()筒ｌｈｉｓａｌ)I)ctite.（)IlAl〕ril０，ＡＩ〕rill2，hevomitedagainandbegant0haverighlul)peI.（luadrantpainal1〔lsystemicitclling、Ｔｈｅｕｒｉｎｅｗａｓｎｏｌｅｄｔｏｂｅ〔lark-colore〔LHewasPI2llelelcoIlnI

bilirubinａｔ４．０ｍｇ/dl,ａｓl)arIateaminotrans陀raselll91U/landalanineamil1otrans化rasel6681U/１，

ｈｅｗａｓreIerlでdtoourhosl)iIaL（)、ａ｡【]lission，ｈｉｓｂｏ〔ｌｙｗｅｉｇｈｔｗａｓ４４ｋｇ，heighIwasl43cm,bodyIemperalurewas36､4℃，
pulsewas96perminute，respirationwas20perminute，ｂｌ()()。'〕ressurewasll()ｍｍＨｇｓｙｓ[()1icand68mmHgdiastolic,bulbal･conjunclivawas
slighl1yicl(､ric，heartexaITlinalionwaswiIhill
nonnallimi1s()nausculalion,theliverwaspalpab1e
３ｃｍｂｅｌ()ｗｌｈｅｃ()stalmargin，ｓｍｏｏｔｈａｎｄ（)Inormalconsislency，ａｎｄ［hegaUbladderregion
wassliRrhllyLenderonpressure・Ｔｈｅｌａｂ()ral()Iy
testresultsareshowninTablelａｎｄ２.Hepalitis
studieswerCnegativefOrhcl)atitisB,Ｃ,ｉｎにctious
mononuclc(〕sis，cytomegalovirusinIeclion，and
mycoplaslnalinfecti()ｎ．1-1()ｗever，ａcutellAV
infectionwas〔liagnosedbydetectinginlmun()‐globu1inM（IgM）antil〕()dics（anti-HAV）ｂｙｅｎｚｙｍｅｉｍｍｕｎｏａｓｓａｙ、Urinalysisshowedbilirubilluria・

Neutrol〕bils
Lymphocytes
MonocyIcs
Eosinol〕hils

52.0％

39.0％
8.0％

1.0％

30.3×101//』』

Table２．Bloodchemistlyvalues,coagulationtests，andserologicaldataonadmission

takenbyhisInothertoal)hysicianagain､Because
hisbloodchelnistlyrevealedhiglllevclsoItolal

13.09/d1

HcmaI()crit

Ｍａｒｃｈ３１，ｈ(､ａｔｅｓｕｓｈｉ【ｌｎｄｂｙＡｐｒｉｌ２，begaI18,hebecamenauseatedandvomitedonce・Then，456×104//(4Tolalpl･(〕teinAlbuminThymo1turbidily[estZincsul｢atelurbidilyl(､slTotalbilirubil】

I)ircc(1〕ilirubill

UreaIIitr()gen
Crealilline

SodiumPo[assiumChloride

Asljarlaleamill()lrans[brfIse
Alanin〔､aminotranslGrase

LacIjcdehydrogenase
Alkalincphosphatase7-gluIamvltranspeplidase
LeuciI1amln()[〕epUdasc
Ca1ciul1l
GIucoscAmmonia

C-reacliveprotein
lHMall[i-HAV(EIA）
Prolhr()mbintimeActivalcdl〕artiallhroml〕()I〕1aslintime
Fibrill()Ren

７．６９/ｄｌ
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２０５Ｕ`1.4ｍｇ/dl
31111g/d１
４．５ｍｇ/d１
０．４ｍｇ/dl
l372mEq/I
45mEq/l
lO32mEq/１
４２５m/111051Ｕ/ll4501U/l
lO271U/I
l711U/］
14501Ｕ/１

８．９ｍｇ/d１
１０７ｍｇ/dl

43/`g/〔１１＜０２ｍR/dｌ`1.9(positive）
９０％

3ｑ９ｓｃｃ()nds

226mg/d］

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scanoltheabdomenalsoindicatedathickened

gallbladderwall(Fig.2)．

Ｎｏｗ,thcpatientiswcllandh℃cfromhel〕atitisA・
Wea1soinvestigatedavirals1rainToanalyze[hesequence,viralRNAli･omserumwasextracLed・Ａｌｔｈｏｕｇｈａｎｔｉｂｉｏｔｉｃｓｗｅｒｅａｄｍｉｎｉｓtered

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ｎｌｕｃ()s〔1,日urr(〕u､〔le(11〕ｖａ［hickerzoneolneal砦ｗａ[erflttelluali()、，ｒ(､|〕rescl1(illgslll)､】uc()sa］edGllMLThe
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infectionwas（liagnosedbyaccepledmclhods，

thatthick(､ｎｉｎｇｏ「thegaublad〔ｌｅｒｗａｌｌｍａｙｂ(PindicalingIhallb(､』&lun(Ii(P〔､wasillduccdasllot

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adjacentliverI)１．YamadaetaLdiscussedinviralhel)alilis．（}()l〔1stciｎ（､Ｉａｌｓ[1ggeslc(lthreeass()cialj()l１ｓｗｉｌlllll()ｎ()l1ucle()sissyll〔1r()ｍｅｉｌｌ

cluesthatau()ＷＣＴ[()〔Iistinguishal〕ericho1ecystic

ｗｈｉｃｈｉｍｍｕｎ()1()ｇｉｃｌ･〔､ａｃｌｉｏｎｓｍｉｇｈ［ｃａｕｓ(、nuidc(〕llecli()nh．(〕milgallbla(lderwaⅡ[hickcningm)．

gaⅡ1)lad(1(ＰｒｗａⅡlhickellil]96)．Fur(her、()lで，Lhey

ＴｈｅＩｉｒｓｔｃｌｕｅｉｓ（ietecti()、（)［【ｗｏｃｏｎｃｅｎｔｒｉｃals(）rel)ｏｒＩｅｄｔｈａ（ｈｙｌ〕Ｃｌ)r()[ｅｉｎｅｍｉａａｎｄ

ｅｎｈａｎｃｉｎｇｒｉｍｓｗｉｔｈｉ、l(wCnil〕ｇｌｏｗ〔](､nsilyｈｙｌ〕oalbuminemiawerel)alh()gellicmechanisms、maLeriaLTh(､ｓec()I】(ｌｃｌｕｅｉｓｌ０ｉ(Ienti｢vsmauHowever,()ｕｒｄａＩａｗｅｒＧｎ()（consistentwiththeirenhancingpunclatcs[ructul･eswiUlilltheapparen【rel)〔〕rt・Ａｓａｎ()(Ｉ１ｅｒｐ()ssibility，Ｓｈａｒｍａｅｔａｌ6６

Ｖｏｌ２０Ｎ仏2,20()４１２７

reporteddirectinvasi()Ｉ１ｂｙｌｈｅｈｅｌ〕ali[isvirusI)．

regionl2･'3)．Ｉtwasnotclearwhethergenolypes

ＷＧｈａｄｔｏｏ化ｗ]〕atien[stoatteml〕ｔａｎｙｃ()rrelaU()nw(〕uldcorrelate［othel)athogenesis()fgallbladderbetweentheetiol()gicaIagentan(Iga]Iblad(1erwall

wallthickeninginihiscase・There｢orｅ［urtllerthickening・CIari[icalionofthel)athogenesisoI

analysisisrequire(Ｌgallbladderwal］thickeningduetohepatilisAＷｈｉｌｅｅｐｉｄｅｍｉｃｓｏｆｈｅｌ)alitisAhavenol
occurrfDdrecGntlyinJal〕an,cases()fhel〕atitisAare

rGquircsfilr[ｈｅｒｓ[udy、ＣＴｒｅｖｅａｌｅｄａｒｅｍａｒｋａｂｌｙｔｈｉｃｋｅｎed
gallbladderwallinourcase・Ｈｏｗever,CTradiation

nolin｢rGqucnLWeshouldstil］payIattenliOnl0
hepatitisA

dose（)I〕timizati()ｎｉｓａｎｉｍｐｏ１－ｔａｎ（issLle・Thel`８０．Ｗ..Ｉ＿

Ａｃｋｎｏｗｌｅｄｇｅｍｅｎｔｓ’bellefiItolhepa[ien（ｏｆａｎａｃｃｕｒａ(ediaRmosissh()uldalwaysbebalancedagainstradiati()nl-isk

Ｗｅｗｏｕｌｄｌｉｋｅｔｏａｃｋｎｏｗｌｅｄｇｅｌ)r・Takehikoan(ｌｔｈｅ1℃ｂｙ，ｉｆｐｏｓｓｉｂ１ｃ，ｗｃｓｈ()ｕｌｄｒｅ〔iuceradiationdoseduetoCTl[)>、Gokan，Ｄｒ・Ｋｕｌ】i(）Ｏ(lagil．i，ａｎｄＤｒ、Ｍａｓａｓｈｉ

Roberts()netalreportedacomprehensive

ＺａｃｈａｒｙＢｅｅｃｒｏｆｔａｎｄＭｒ・ＰａｕｌＡｒｅｎｓ()nfor

Ｙａｌｓｕｚｕｋａｆ()ｒｇｒａｔｅ[ｕｌａｄｖｉｃｅａｓｗｅｌ１ａｓＭｒ、

analvsisofsc〔luencedaladerivedfromlheVP1/2A
juI1ctionregion,1℃sultinginlhe〔1elinitiono[sevcnassistinginmanuscriptpreparation．

uniquegenotyl)eｓ（ＩｔｏＶＩＩ)'')．Ｆｏｕｒ()［[heseAnnualMeelingofTheJapaneseSocietylor

g〔､､(〕typeｓ(1,11,IILａｎ(1ⅥI)havebeenass()ciatedwill1humandiseaso11)．

Pe〔liaI1･icGastl-0enterol()ｇｙ，ＨｅｐａｌｏｌｏｇｙａｎｄＡＩ)reliminaryreporLwaspresentedatthe29th

Ｎｕｔｒｉ(i0,,21-22Septembe]-,2002.

AccordinglotheinvesUgationo［thepubliclleaIthcentcr【r()ｍＭａｒｃｈ２５１ｏＡｌ)ｒｉｌｌ９，２２１)aUentsincluding()url)alienlan〔1hismotllcrw()realsosu〔[eringfromhepatitisA・OIthetotal22

palienls，l9weremalcand3wereIemale・Ｏｕｒｐａ(ientwas(ｈｅ()I1lyl〕edia(riccase・Ｔｈｅｙａｌ］ale
suslliatthｅｓａｍｅｓｕｓｈｉｓｈｏｐ・IndividuaIviralis()lateswereassembledfromclinicalspecimensc()nlainiI】ｇＨＡｙ(stools()rserum).Ｏ[ｉｈｅｔ()tal22

pa(ients，l7patienlswh()includedl5malesand2IemaleswereinvestigatedforUleviralstramTheviralstrainfromihespocimensoIall[hesel〕atientswasclassiIiedaslAsubgenotype､TherefOre,therewasanepidemicofhel)atitisA.（)urHndings［hａｔｔｈｅｍａｊｏｒｉｔｙｏｆＨＡＶｉｎｏｕｒｐａｔｉeｎＩｓｉｓ（)IsubgenotypeIAisconsistentwiththeprevioL1sreportl】).
Toourknowledge,therearenoreportsthat
genomicdi[[erencesofHAVarcresponsible［Ｃｌ・thegaUl〕ladderwallthickening・Fujiwaraetal、
suggestedthatviralfactorsmightｂｅｉｎｖｏｌｖｅｄｉｎｄｅ[enniningtheseverityofthedisease・However，
ｔｈｅｙｒｅｐｏｒｔｅｄｔｈａｔｄｉｓｅａｓｅｓｅｖｅｒｉｔywasnot
associatcdwithlheHAVgenotype-determining

Referencesl）SnyderJI)，PickeringLK・ViralhepaLitis・Ｉ、：
Behl･ｍａｎＲＥ,ＫｌｉｅｇｍａｎＲＭ,ＪｅｎｓｏｎＨＢ,cditors・
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