A Hard Diagnosis

今回は、"hard"をギリシア語の"σκληρά"と掛けたタイトルです。（大ヒントです！）ところで、今回は、著者にTierney先生とDhaliwal先生がお名前を連ねております。ちなみに、本連載でのお二人が著者に名を連ねている回数は、Tierney先生が10回、Dhaliwal先生が11回、お二人共著が今回１回のみとなっており、まさしく記念碑的な回と申せましょう。（プレゼンターは、さぞ緊張したろうな！）付け加えれば、Saint先生は57回！

A CLINICAL PROBLEM-SOLVING article by Mary Margaretten from University of California, San Francisco.
A 56-year-old woman presented to the emergency room with a 4-week history of malaise. During that time, her primary physician had ordered basic laboratory studies, which were normal except for a white-cell count of 16,000 per cubic millimeter. She had taken a sulfa antibiotic, but the malaise persisted. For many years, she periodically had an urticarial rash on her arms.
On physical examination, the blood pressure was 160/80 mm Hg. She had bilateral periorbital edema. Her skin had diffuse patchy areas of depigmentation on the arms, chest, neck, face, and scalp that were consistent with vitiligo. The erythrocyte sedimentation rate was 99 mm per hour. The patient's serum serum creatinine level was 8.9 mg per deciliter. It had been 1.0 mg per deciliter 4 weeks earlier.
On hospital day 1, raised, erythematous, pruritic plaques developed on the patient's arms and legs, similar to those in previous episodes. The serum creatinine level rose to 10.7 mg per deciliter.
Features of diseases often unfold over time rather than all at once. The current case highlights how context, rather than simple knowledge, affects our diagnostic insights. The diagnosis was reached through a systematic process of eliminating competing causes of renal failure and interpreting the kidney pathology in light of an autoimmune diathesis and ongoing hypertension. [Original Article]

非特異的な症状に関するコメント

• Malaise is commonly reported and offers little in the way of a focused differential diagnosis.

既往歴からの考察

• The history of urticaria, thyroiditis, and vitiligo raises the possibility of other autoimmune disorders such as Addison's disease or diabetes mellitus to explain the fatigue.