한국산학기술학회논문지 (Journal of the Korea Academia-Industrial cooperation Society)

  • 제18권10호
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  • Pages.178-184
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  • 2017
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  • 1975-4701(pISSN)
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  • 2288-4688(eISSN)
한국산학기술학회 (The Korea Academia-Industrial cooperation Society)
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쯔쯔가무시병과 동반된 뇌경색의 특징

Feature of cerebral infarction with tsutsugamushi disease

  • 최판규 (조선대학교의과대학 신경과학 교실) ;
  • 강현구 (조선대학교의과대학 신경과학 교실)
  • Choi, Pahn Kyu (Department of Neurology, Chosun University School of Medicine) ;
  • Kang, Hyun Goo (Department of Neurology, Chosun University School of Medicine)
  • 투고 : 2017.05.12
  • 심사 : 2017.10.13
  • 발행 : 2017.10.31
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초록

본 연구는 2007년 1월부터 2015년 12월까지 본원에서 쯔쯔가무시병으로 진단을 받고 치료 중인 상태에서 뇌경색이 발생하거나, 뇌경색이 생겨 입원 치료를 받던 중 쯔쯔가무시병이 발견된 16명의 환자를 대상으로 하였다. 급성기 뇌경색의 진단은 뇌자기공명영상 및 뇌자기공명혈관영상으로 하였으며 쯔쯔가무시병의 진단은 PCR (Polymerase chain reaction)로 하였다. 일반적인 뇌경색과 쯔쯔가무시병을 동반한 뇌경색의 차이점을 구별하기 위해 내원시 혈압과 체온을 측정하여 보았다. 일반적으로 급성기 뇌경색에서는 혈압이 올라가는데 흥미롭게도 본 연구에서는 수축기 혈압이 130mmHg 미만인 환자가 12명으로 급성기 뇌경색에서 흔히 보이는 혈압 양상과는 다른 모습을 보였다. 쯔쯔가무시병을 동반한 뇌경색의 특징을 알아보기 위해 발병 위치 및 단일 혹은 다발성 뇌경색 여부를 확인하여 보았는데, 앞순환 동맥 영역의 뇌경색 발생 환자가 13명이었으며 뒤순환 동맥 영역의 뇌경색 발생 환자는 3명이었다. 응고장애를 진단하기 위해 트롬보플라스틴시간(Prothrombin Time, PT), 활성화부분트롬보플라스틴시간(activated partial thromboplastin time, aPTT), D-dimer, 섬유소원(fibrinogen), 섬유소분해산물(fibrin degradation product, FDP)를 기록하였다. 뇌경색시 일반적으로 수치가 증가하는 것으로 알려진 D-dimer의 경우 13명의 환자에서 큰 폭의 증가 소견을 보였다. 섬유소분해산물(FDP)는 15명의 환자에서 큰 폭의 증가 소견을 보였다. 쯔쯔가무시병의 병태생리학적 기전은 혈관염으로 알려져 있는데 이로 인한 대뇌혈관의 내피세포 손상 및 증식이 있을 수 있고 그 과정에서 응고장애가 동반되어 뇌경색이 발생할 수 있다. 또는 내피세포 손상 및 증식이 없더라도 혈관염으로 인한 혈관연축이 발생하여 혈관수축이 오며 뇌경색이 발생 할 수도 있다.

This study was performed on 16 patients diagnosed with tsutsugamushi disease and cerebral infarction from January 2007 to December 2015. An acute cerebral infarction was diagnosed by brain MRI and MRA. Tsutsugamushi disease was diagnosed using a polymerase chain reaction. To distinguish the difference between the generalized cerebral infarction and infarction with tsutsugamushi disease, the blood pressure and body temperature were measured uponadmission. In general, the blood pressure increases during an acute cerebral infarction. Interestingly, in this study, 12 patients showed a systolic blood pressure less than 130 mmHg uponadmission. The location of the cerebral infarction and whether single or multiple cerebral infarction were examined. Thirteen patients had a cerebral infarction in anterior circulation and 3 patients developed in posterior circulation. To evaluate the coagulation disorders, prothrombin time (PT), activated partial thromboplastin time (aPTT), D-dimer, fibrinogen, fibrin degradation product (FDP). D-dimer, which is generally known to increase in an acute cerebral infarction, showed a significant increase in the 13 patients. Fibrin degradation products (FDP) showed a significant increase in 15 patients. The pathophysiological mechanism of tsutsugamushi disease is known as vasculitis, which may result in an endothelial cell injury and proliferation of the endothelial wall, which may lead to a cerebral infarction accompanied by coagulopathy. Without endothelial cell damage and proliferation, a vasospasm caused by vasculitis may cause vasoconstriction and cerebral infarction.

키워드

참고문헌

  1. Watt G, Kantipong P, Jongsakul K, Watcharapichat P, Phulsuksombati D, Strickman D, "Doxycycline and rifampicin for mild scrub-typhus infections in northern Thailand: a randomized trial," Lancet sep 23, vol. 356, no. 9235, pp. 1057-61, 2000. https://doi.org/10.1016/S0140-6736(00)02728-8
  2. Silpapojakul K, Ukkachoke C, Krisanapan S, Silpapojakul K., "Rickettsial meningitis and encephalitis," Arch Intern Med Sep; 151, pp. 1753-1757, 1991. https://doi.org/10.1001/archinte.1991.00400090051010
  3. Premaratna R, Chandrasena TG, Dassayake AS, Loftis AD, Dasch GA, de Silva H. J., "Acute hearing loss due to scrub typhus: a forgotten complication of a reemerging disease," Clin Infect Dis Jan 1, vol. 42, no. 1, pp. 6-8, 2006. https://doi.org/10.1086/498747
  4. Moron CG, Popov VL, Feng HM, Wear D, Walker D. H., "Identification of the target cells of Orientia tsutsugamushi in human cases of scrub typhus," Mod Pathol Aug, vol. 14, no. 8, pp. 752-9, 2001. https://doi.org/10.1038/modpathol.3880385
  5. Lin W. Y., Lin G. M., Chang F. Y., "An unusual presentation of scrub typhus with atraumatic hemoperitoneum," Am J Gastroenterol Apr vol. 104, no. 4, 1067, 2009. DOI: https://doi.org/10.1038/ajg.2009.8
  6. Kim D. G., Kim J. W., Choi Y. S., Kim S. H., Kim S. M., Park C. G., Seo H. S., Oh D. J., "Acute myocardial infarction following scrub typhus infection," Int J Cardiol Jan 2;vol. 114, no. 1, pp. 18-20, 2007. DOI: http://dx.doi.org/10.1016/j.ijcard.2006.07.131
  7. Schmaier AH, Srikanth S, Elghetany MT, Normolle D, Gokhale S, Feng HM, Walker DH, "Hemostatic/fibrinolytic protein changes in C3H/HeN mice infected with Rickettsia conorii-a model for Rocky Mountain spotted fever," Thromb Haemost Sep, vol. 86, no. 3, pp. 871-9, 2001. https://doi.org/10.1055/s-0037-1616145
  8. Ben-Zvi IE, Meltzer O, Feld I, Bank., "A case of murine typhus associated with large vessel infarct of the spleen," Am J Med Sci Jun, vol. 335, no. 6, pp. 502-3, 2008. DOI: https://doi.org/10.1097/MAJ.0b013e3181586633
  9. U. K. Misra, J Kalita, V. E. Mani, "Neurological manifestations of scrub typhus," J Neurol Neurosurg Psychiatry, Jul, vol. 86, no. 7, pp. 761-6, 2015. DOI: https://doi.org/10.1136/jnnp-2014-308722
  10. Jong-Hoon Chung, Na-Ra Yun, Dong-Min Kim, Ji-Woon Lee, Sung Ho Yoon, Seok-Won Kim, "Case Report: Scrub Typhus and Cerebrovascular Injury: A Phenomenon of Delayed Treatment?," Am. J. Trop. Med. Hyg, Jul, vol. 89, no. 1, pp. 119-22, 2013. DOI: https://doi.org/10.4269/ajtmh.13-0094
  11. Jae Han Park, Oh-Dae Kwon, Dong Kuck Lee, "Cerebral Infarction Associated with Scrub Typhus," Korean J Stroke 9, pp. 168-170, 2007.
  12. Paul Trowbridge, Divya P, Prasanna S. Premkumar, George M. Varghese, "Prevalence and risk factors for scrub typhus in South India," Trop Med Int Health, vol. 22, no. 5, pp. 576-582, May 2017. https://doi.org/10.1111/tmi.12853
  13. Qureshi A. I., "Acute hypertensive response in patients with stroke: pathophysiology and management," Circulation, vol. 118, no. 2, pp. 176-87, Jul. 2008. https://doi.org/10.1161/CIRCULATIONAHA.107.723874
  14. Shin H. K., Nishimura M, Jones PB, Ay H, Boas DA, Moskowitz MA, Ayata C., "Mild induced hypertension improves blood flow and oxygen metabolism in transient focal cerebral ischemia," Stroke, vol. 39, no. 5, pp. 1548-55, May 2008. https://doi.org/10.1161/STROKEAHA.107.499483
  15. Hillis A. E., Ulatowski J. A., Barker P. B., Torbey M., Ziai W., Beauchamp N. J., Oh S., Wityk R. J., "A pilot randomized trial of induced blood pressure elevation: effects on function and focal perfusion in acute and subacute stroke," Cerebrovasc Dis, vol. 16, no. 3, pp. 236-46, 2003. DOI: https://doi.org/10.1159/000071122
  16. Yamauchi H, Higashi T, Kagawa S, Kishibe Y, Takahashi M., "Impaired perfusion modifies the relationship between blood pressure and stroke risk in major cerebral artery disease," J Neurol Neurosurg Psychiatry, vol. 84, no. 11, pp. 1226-32, Nov. 2013. DOI: https://doi.org/10.1136/jnnp-2013-305159
  17. Ono Y, Ikegami Y, Tasaki K, Abe M, Tase C., "Case of scrub typhus complicated by severe disseminated intravascular coagulation and death," Emerg Med Australas, vol. 24, no. 5, pp. 577-80, Oct. 2012. DOI: https://doi.org/10.1111/j.1742-6723.2012.01600.x