風土病 - From the Soil by the Wind

5月27日にＴＶ東京で放送された「実録世界のミステリー」のホントに怖い！危険な病原菌 Case4 「恐怖の病原菌 大都市の空を舞う」の正体は、アメリカ南西部の風土病、コクシジオイデス症でした。地中の胞子がノースリッジ地震にて空中に舞い上がり、砂塵雲となって拡散したケースです。土から舞い上がり、風に乗って拡散、字義通りの風土病です。Soil & Windが、SouthWestの頭文字と一致するのも、何かの縁。

アメリカの風土病については理解するには、その地理についての知識が必須。大雑把にアメリカ本土の臍がカンザス州で、南北に貫くフロンティアフロント以西で、カンザス州以南が、広義の南西部、狭義には、フォーコーナーの南半分、つまりアリゾナ、ニューメキシコあたりが南西部の中核となる。

合衆国の国勢調査局による地域区分は次のとおり。

北東部

• ニューイングランド：メイン州、ニューハンプシャー州、バーモント州、マサチューセッツ州、ロードアイランド州、コネチカット州 (6)
• 大西洋側中部：ニューヨーク州、ニュージャージー州、ペンシルベニア州(3)

中西部

• 東北中部：ミシガン州、ウィスコンシン州、オハイオ州、インディアナ州、イリノイ州 (5)
• 西北中部：ミネソタ州、ノースダコタ州、サウスダコタ州、アイオワ州、ネブラスカ州、ミズーリ州、カンザス州 (7)

南部

• 大西洋側南部：デラウェア州、メリーランド州、ウエストバージニア州、バージニア州、ノースカロライナ州、サウスカロライナ州、ジョージア州、フロリダ州(8)
• 東南中部：ケンタッキー州、テネシー州、アラバマ州、ミシシッピ州(4)
• 西南中部：アーカンソー州、オクラホマ州、ルイジアナ州、テキサス州(4)

西部

• ロッキー山脈地帯：モンタナ州、ワイオミング州、アイダホ州、コロラド州、ユタ州、ネバダ州、ニューメキシコ州、アリゾナ州(8)
• 太平洋側：ワシントン州、オレゴン州、カリフォルニア州、アラスカ州、ハワイ州(5)

References

• Holenarasipur R. Vikram, M.D., Gurpreet Dhaliwal, M.D., Sanjay Saint, M.D., M.P.H., and C. Blake Simpson, M.D. CLINICAL PROBLEM-SOLVINGA Recurrent Problem  N Engl J Med 2011; 364:2148-2154June 2, 2011
• Schneider E, Hajjeh RA, Spiegel RA, et al. A Coccidioidomycosis Outbreak Following the Northridge, Calif, Earthquake. JAMA. 1997;277(11):904-908. 

A Perfect Storm

"A Perfect Storm" by William Janssen.
This clinical problem solving article concerns a 21-year-old male college student who presented to the student health center after two days of extreme fatigue. Over the course of the previous two months, frequent headaches, difficulty concentrating, and a decrease in his capacity for exercise had developed. He recently had had several days of nasal congestion and sore throat, but these symptoms had improved. A cursory physical examination showed no abnormalities, but his oxygen saturation on pulse oximetry was only 55 percent, which was most unexpected.
The blood gas values indicated a respiratory acidosis.
The discussant and clinical analysis examinee approached to the diagnosis in the patient with the evidence of hypoventilation.

"perfect storm"は、ほぼ"worst-case scenario"と同義である。1991年に合衆国東海岸を襲ったハリケーンやそれを題材とした小説、映画のタイトルとして日本においてもこの語法が認知されるようになった。

A Hole in the Argument

This CLINICAL PROBLEM-SOLVING article describes an 80-year-old man who was evaluated of shortness of breath and fatigue four weeks after repair of a hiatal hernia. He reported a mild, nonproductive cough and abdominal bloating. Prior to the surgery, he had been very active and had had no dyspnea.
The patient had a history of coronary artery disease but no history suggested pulmonary disease.
He was found to have a substantial reduction in arterial oxygen saturation, with a a partial pressure of oxygen of 35 mm Hg. The findings on physical examination were unremarkable.
The normal cardiac examination and clear lung fields suggest that heart failure or significant pulmonary parenchymal disease is unlikely to explain his dyspnea. Pure oxygen was administered, but it did not improve his severe hypoxemia.
Transthoracic echocardiography was performed and videos of these may be reviewed at www.nejm.org.
This discussion by Donald Hegland highlights the challenge of determining the clinical significance of a common anomaly.

Needle in a Haystack

A 63-year-old man presented to the emergency department with shortness of breath that had begun the evening before, after he had gone to bed, and worsened progressively during the night. He had had no fevers, chills, cough, hemoptysis, chest pain, or peripheral edema and had no history of congestive heart failure. Five months earlier, a pulmonary embolus had been diagnosed, for which he received warfarin maintenance therapy; the results of prothrombin-time testing, expressed as an international normalized ratio, were consistently above 2.0.
The patient had a history of smoking and hypertension in conjunction with evidence of peripheral vascular disease.
Many disorders can present with a sudden onset of shortness of breath, some of which are medical emergencies.
This clinical problem-solving article by Krishna Polu of the Brigham and Women's Hospital and Myles Wolf of Massachusetts General Hospital highlights the the challenge of diagnosing a syndrome with nonspecific symptoms and indolent nature.

Empirically Incorrect

A CLINICAL PROBLEM-SOLVING article by Amy Schmitt from Legacy Emanuel and Legacy Good Samaritan Hospitals in Portland, Oregon.
A 46-year-old Mexican immigrant presented with epigastric pain and vomiting of coffee-grounds material. He reported fatigue, malaise, jaundice, and a weight loss of 20 lb during the previous two months. He had also had dark stools, light-headedness, and mild shortness of breath, but no fever, chills, or night sweats.
Analysis of a peripheral-blood smear showed nucleated red cells. Endoscopy revealed a duodenal ulcer; a urease enzyme test of a biopsy specimen was positive for H. pylori. A liver biopsy was performed.
On the basis of the insidious nature of this patient's illness, the fever and lymphadenopathy, and the history of exposure to livestock, he was treated empirically for brucellosis and he was treated for H. pylori.
When his condition ??? improve, he was treated with empirical prednisone for presumed granulomatous hepatitis.
In this case, the delay in diagnosis, compounded by the subtlety of the finding on the initial liver-biopsy specimen, resulted in a substantial delay in identifying the cause of the patient's jaundice.
When a patient's condition worsens despite the use of empirical therapy, clinicians must decide whether to continue the empirical therapy, change the empirical therapy, or repeat diagnostic testing.

Search for the Complication

A CLINICAL PROBLEM-SOLVING article by Francis Salamon from Rabin Medical Center in Israel and colleagues.
A 58-year-old woman was hospitalized for evaluation of prolonged fever and hemoptysis. She reported having had intermittent fevers, a productive cough, shortness of breath, and hemoptysis during the previous eight months. CT of the chest revealed peripheral infiltrates in the upper lobe of the left lung and lingula and a calcified left hilar opacity, with additional, small mediastinal lymph nodes. Bronchoscopy demonstrated hyperemic bronchi. Culture of a bronchial-lavage specimen was positive for a nontuberculous, slow-growing mycobacterium. Staining and culturing were negative for M. tuberculosis. A tuberculin skin test was positive.
The patient had a history of hypertension, chronic atrial fibrillation, inflammatory bowel disease, and hypothyroidism that was attributed to the use of amiodarone. She had undergone catheter ablation procedure one year earlier, after which the amiodarone had been stopped.
The laboratory finding and the results of CT angiogram and ventilation–perfusion lung scans are discussed.
A diagnosis made after much testing sometimes raises the question of why the correct diagnosis was not made earlier. In some cases, diseases are overlooked because they are rare, mimic other diseases, or present atypically. The diagnosis of a relatively new clinical syndrome is especially challenging. This case concerns such a challenge.

演者の施設、イツハク・ラビンの名を冠したRabin Medical Centerは、Clalit Health Care Serviceが運営するイスラエルのトップレベルの病院。

A Jaundiced Eye

A CLINICAL PROBLEM-SOLVING article by John Amory from University of Washington, Seattle and colleagues.
A previously healthy 27-year-old man presented to his primary care physician six days after the onset of a nonproductive cough, sore throat, and a feeling of being “run down.” During the preceding week, he had also noted fever and diffuse abdominal pain that was mild to moderate in intensity. Two days before presentation, he noticed dark-colored urine and that his eyes were red and itchy, with a clear, thick discharge.
Three days after the initial clinic visit, the patient began to have nausea and vomiting, jaundice, and worsening cough. He had a temperature of 39°C.
Two days later, the patient returned to his primary care physician with dyspnea, worsening cough, and a pruritic rash on both arms. A chest X ray revealed bilateral pulmonary infiltrates. The patient had scleral icterus with mild conjunctivitis. In addition, shotty anterior cervical lymphadenopathy was noted.
In this case, some atypical features may have increased the difficulty of finding the correct diagnosis of a severe multisystem disorder in a previously healthy host. In making the diagnosis, the discussant places weight on the most important features of the patient's presentation, and is not overly distracted by anomalous findings.

"jaundiced eye"には、「偏見の目を持った見方」という意味があり、この場合、jaundicedは、prejudiced, biased, distortedなどと同義。

Ring around the Diagnosis

A CLINICAL PROBLEM-SOLVING article by Maria-Fernanda Bonilla from Cleveland Clinic Foundation, Ohio and colleagues.
A 71-year-old retired schoolteacher from rural Ohio presented to his local hospital with a two-week history of malaise, fever, anorexia, chills, and sweats. He had not had a cough or symptoms involving the upper respiratory, gastrointestinal, or urinary tract.
The patient appeared diaphoretic. The blood pressure was 113/58 mm Hg, the heart rate 66 beats per minute, and the respiratory rate 18 breaths per minute and not labored. The temperature was 38.4°C orally.
Three months before his illness, his wife had had an influenza-like febrile illness that left her bedridden for two weeks; she had recovered fully. The reported no travel outside the Midwest.
The patient was admitted with a presumptive diagnosis of urinary tract infection and was treated with intravenously administered ampicillin–sulbactam. Despite continued antibiotic therapy, the patient's clinical status deteriorated during the ensuing two weeks. The fever persisted, and the creatinine level increased to 2.9 mg per deciliter. The total bilirubin level increased to 6.0 mg per deciliter and the conjugated bilirubin level increased to 5.3 mg per deciliter.
In this patient, rapid clinical deterioration mandated an aggressive strategy.
This case discussion explains have the evidence directed the team toward a potentially risky diagnostic procedure, a liver biopsy in a patient with mild coagulopathy. But the result of the liver biopsy changed the diagnostic approach.

今回は、Q熱。不明熱の場合、字義的に筆頭であってもよさそうだが、症例がレアなこともあり、漏がちな疾患。少なくともペット飼育や職業について聴いておくことが重要。

Thinking outside the Box

A CLINICAL PROBLEM-SOLVING article by Ramin Farzaneh-Far from Brigham and Women's Hospital, Boston and colleagues.
A 35-year-old man with advanced AIDS presented to the emergency department after a witnessed syncopal event. He had light-headedness after walking from the bathroom. While speaking to his partner, he suddenly became unresponsive and lost motor tone, and his breathing appeared shallow and labored, prompting his partner to call 911. The man regained consciousness after approximately two minutes and had no recollection of the event. There was no evidence of tonic–clonic seizure activity or postictal confusion. He reported no chest pain, cough, palpitations, pleurisy, vertigo, shortness of breath, fevers, chills, nausea or vomiting, or incontinence.
A detailed history from an eyewitness is invaluable in evaluating a patient with syncope and distinguishing true syncope from seizure. Although this patient's history of HIV infection puts him at risk for several conditions that might result in seizure, the absence of observed sustained tonic–clonic movements, confusion or drowsiness after the syncopal event, and urinary incontinence argue against this diagnosis.
This case highlights the effect of the ability to “think outside the box” is critical to avoid missing this diagnosis, particularly in patients whose underlying diseases may otherwise suggest alternative explanations for presenting symptoms.

重要視されていても正確な診断が困難なのが肺塞栓症。 エコーの所見を2つほどメモ。

• McConnell's sign(hypokinesis of the right ventricular free wall with sparing of the right ventricular apex in the presence of preserved left ventricular systolic function) : sensitivity 77%, specificity 94% 
• 60/60 sign (Pulmonary ejection acceleration time in RVOT of 60ms in the presence of tricuspid insufficiency oressure gradient 60mmHg): sensitivity 26%, specificity 89%

Heading Down the Wrong Path

A CLINICAL PROBLEM-SOLVING article by Michael Detsky from University of Toronto, Ontario, Canada.
A 52-year-old woman experienced the sudden onset of bilateral arm tingling and numbness, and noted that the words on her computer screen appeared “mixed up.” Her condition improved during the next 24 hours, but difficulty swallowing and slurred speech developed, and worsened during the next three days until she was unable to speak. The day before presentation, bilateral impairment of the left visual field developed and she became lethargic. Her family sought medical care for her.
A chest x-ray revealed no abnormalities. Blood studies were within normal limits. CT of the brain showed no obvious lesions.
Follow-up cardiovascular examination was normal. Neurologic examination revealed a number of abnormalities that suggested the presence of lesions in the cerebellum and right hemisphere.
MRI of the brain demonstrated multiple hyperintense lesions on T2-weighted and fluid-attenuated inversion recovery images.
The paitient was treated with cyclosporine and thyroxine. Although there was apparent resolution of some lesions, progression of others is evident elsewhere, indicating active disease.
This case reveals the rare condition, facing the challenging cause, the patient's physicians headed down the wrong path before ultimately reaching the correct diagnosis.

「第303回　東京レントゲンカンファレンス」を参照。

A Sharp Right Turn

A CLINICAL PROBLEM-SOLVING article by Anupam Mohanty from University of South Florida College of Medicine in Tampa.
A 60-year-old man presented to the emergency department for evaluation of rectal bleeding, syncope, and pain in the right leg. Five days earlier, diffuse abdominal pain that worsened with movement had developed in association with nausea, anorexia, and malaise. He had not traveled recently or ingested any unusual foods. Approximately six hours before admission, he had a single episode of gross hematochezia and hematuria followed by syncope and an intense pain in his right leg.
This patient presented with multisystem findings, for which a unifying diagnosis is not immediately clear. This case involves collaboration with internist, gastroenterologist and vascular surgeon to reveal an unusual surgical condition with signs and symptoms that are similar to those of several intraabdominal diseases.

ちょいと脱線。面舵、取舵は、それぞれ干支の卯（東）、酉（西）に由来するそうだ。それに対し、英語のstar board、portは、操舵席のある側が右なのでsteer boardが訛り、接岸する左側がportというらしい。前者は、接岸する反対側なので星が良く見え、star boardという説もあるとか。

More Than Meets the Eye

A CLINICAL PROBLEM-SOLVING article by John Nguyen from Johns Hopkins University School of Medicine, Baltimore, Maryland.
A 61-year-old woman was hospitalized with a two-day history of palpitations and dyspnea. She was found to be in atrial fibrillation with a rapid ventricular response, and intravenous diltiazem and a heparin infusion were begun. Her condition improved, but on the third hospital day, she reported feeling weak and nauseated and began passing dark red urine. She did not have a urinary catheter, dyspnea, back pain or dysuria.
The hematocrit 30% was compared with 35% at admission. Urinary dipstick testing revealed high levels of hemoglobin and 3 plus protein. Results of urine testing for myoglobin were negative.
Often, clinicians encounter new problems during the course of a patient's hospitalization that are unrelated to the initial reasons for admission. In this case, the patient's symptoms developed while she was being treated with anticoagulants for atrial fibrillation. 

最近は、英語に合わせて「発作性夜間ヘモグロビン尿症」と呼ばれるのですね。Marchiafava-Micheli症候群という冠名もあるようですが。

Lost in Transcription

A CLINICAL PROBLEM-SOLVING article by Robert Kalus from University of Washington, Seattle.
Urinary urgency and fever developed in a 55-year-old, bedridden woman with multiple sclerosis, a long-term indwelling Foley catheter, and multiple prior urinary tract infections. The patient had recently been transferred from an assisted-living facility to a skilled-nursing facility because of progressive disability. On the day of presentation, she reported urinary urgency and dysuria, despite a normally functioning urethral catheter; her temperature was 38.5°C.
Her long-term medications included ranitidine for reflux symptoms, rofecoxib for pain control, baclofen for spasticity, gabapentin for neuropathic pain, and weekly methotrexate as corticosteroid-sparing therapy for her progressive multiple sclerosis. She had also mouth pain and fatigue for several days before presentation.
On examination at the emergency department, the patient was thin, somnolent, diaphoretic, and ill-appearing. She had notable dry oral mucosa, with desquamation of her tongue, palate, and buccal surfaces.
Laboratory testing revealed a white-cell count of 330 per cubic millimeter, with an absolute neutrophil count of 50; the platelet count was 7000, and the hematocrit was 34%; serum creatinine, 1.0 mg per deciliter, increased from 0.5 mg 10 weeks earlier.
In this case, after initially considering a broad differential diagnosis, the discussant quickly focused on the possibility of medical error.

メソトレキセート処方の転記(transcription)ミスによる骨髄抑制のケース。この薬剤は、「白質脳症」にも気をつける必要がある。

The Missing Piece

A CLINICAL PROBLEM-SOLVING article by Kathryn Robertson from University of Colorado Health Sciences Center in Denver.
A 21-year-old man presented to the emergency department after a 2-day history of increasing pain in the right lower quadrant. He had had exertional dyspnea and a cough productive of scanty yellow sputum for a month.
He had previously been employed as a sushi chef, but he had not worked for 3 months. He had not ingested raw shellfish but had prepared raw crayfish and crab. 4 years before presentation, he had spent 3 months visiting relatives in rural areas of South Korea.
Laboratory analysis revealed peripheral blood eosinophilia and a chest X ray showed moderate-sized, bilateral pleural effusions.
One of the most effective strategies involves pattern recognition, in which the clinician breaks the case down into manageable pieces and compares features of the current case with ones he or she has seen in the past. New cases are then recognized as similar or identical to old ones that have already been solved. In the case under discussion, the clinician focused on two patterns of disease with which he was familiar: abdominal pain and respiratory disease.

今回は、폐흡충(肺吸蟲)でした。

Sum of the Parts

A CLINICAL PROBLEM-SOLVING article by Meeta Prasad from Yale University School of Medicine in New Haven, Connecticut.
A 36-year-old Pakistani woman presented to the emergency room with a 10-day history of a nonproductive cough, dyspnea, and fever. She reported having no night sweats and no contact with anyone who was ill, including anyone with known tuberculosis. She had been seen 1 week earlier at a walk-in clinic, where she received a prescription for moxifloxacin for presumed bronchitis, but her symptoms persisted.
At the emergency room, she presented with petechiae, pulmonary hemorrhage, azotemia, proteinuria, and hematuria.
This case represents an uncommon presentation of a common disease. Recognizing the sum of the parts of this patient's complicated presentation ultimately led to the correct diagnosis and to effective therapy.

参考文献

• 本邦のC型慢性肝疾患におけるクリオグロブリン血症についての検討　日消誌94(4)242-247, 1997

A Stain in Time

A CLINICAL PROBLEM-SOLVING article by Jeremy Jones from University of Toronto, Canada.
A 45-year-old woman from northern Ontario presented to her local hospital with a 2-year history of asymmetric migratory arthralgias involving the left knee, ankles, elbows, and fingers. She also had morning stiffness, increasing fatigue, an erythematous, nonpruritic rash after sun exposure, and a 3-month history of chest pain that was relieved when she was in an upright position. She did not have fevers, dry eyes or mouth, oral ulcers, or eye irritation or pain.
The patient's physicians made a diagnosis of seronegative lupus and started treatment with hydroxychloroquine. However, this conclusion was premature; the patient did not meet formal criteria for the diagnosis, antinuclear antibody–negative lupus is rare, and other more common conditions (such as inflammatory bowel disease and chronic infections) warranted consideration first. As the case unfolded over a period of several years, the chronic nature of the illness, the evolution of new constitutional symptoms, and the manifestations of malabsorption led to reconsideration of the initial diagnostic hypothesis and ultimately to conclusive diagnostic testing of duodenal tissue and cerebrospinal fluid.

Whipple病に関する資料

• Whipple's Disease via NEJM 
• Whipple病は病理学者により1907年に初めて報告された疾患 via 感染症の病理学的考え方 
• Whipple 病はマクロファージ内のPAS陽性物質と脂質沈着が特徴 via 感染症の病理学的考え方

Anchors Away

A CLINICAL PROBLEM-SOLVING article by Carolyn Calfee from University of California, San Francisco.
A 50-year-old Asian woman presented with a papulonodular, erythematous rash on her legs below the knees. The skin lesions were nontender and nonpruritic and were accompanied by paresthesias.
A biopsy of one of the skin lesions showed granulomatous dermatitis. Stains and cultures for acid-fast bacilli and fungal organisms were negative. On the basis of the clinical and histopathological findings, a diagnosis of sarcoidosis was made by the patient's physician.
A chest radiograph reportedly revealed scattered nodules and increased interstitial markings that were considered to be consistent with sarcoidosis. Three months later, shortly before her appointment with the pulmonologist, dyspnea on minimal exertion, hoarseness, and dysphagia with both solids and liquids developed.
In this case, several findings support the diagnosis of sarcoidosis. None of these findings, however, are specific enough to be considered diagnostic of sarcoidosis.
Why did the physicians initially involved in this case settle on a diagnosis of sarcoidosis? They most likely fell prey to two types of cognitive bias: the availability and anchoring heuristics.
The clinicians initially accepted the diagnosis and were falsely anchored to it from that point onward.

最終診断は、リンパ腫様肉芽腫症(lymphomatoid granulomatosis)だが、Discussantはサルコイドーシスにアンカリングされてしまった。

Into the Woods

A CLINICAL PROBLEM-SOLVING article by Nasia Safdar from University of Wisconsin–Madison.
A 79-year-old woman presented with a 1-month history of dyspnea and a cough productive of yellow sputum. She reported no chest pain, hemoptysis, night sweats, or fever.
Three months earlier, the patient had been clinically diagnosed with giant-cell arteritis. And she was placed on 40 mg of oral prednisone daily which she was still taking at the time the pulmonary symptoms developed.
The patient was retired and spent a great deal of time in the woods around her home in Wisconsin.
On physical examination, the patient was a thin, elderly woman in no acute distress.
The erythrocyte sedimentation rate was 117 mm per hour; C-reactive protein was 27 mg per deciliter. A chest radiograph revealed air-space opacity in the left upper lobe.
Several days after admission, repeated chest ray showed worsening disease.
Gram's staining of a sputum specimen revealed beaded, branching, gram-positive rods.
Correctly and efficiently diagnosing the cause of pulmonary disease in an immunocompromised patient is challenging. Knowledge of the rate of disease progression and the type of immune compromise is useful in the initial differential diagnosis. A detailed history to elicit epidemiologic exposures further refines the possible diagnoses. Finally, the pattern of lung involvement can also help narrow down the possible causes.

Building a Diagnosis from the Ground Up

A CLINICAL PROBLEM-SOLVING article by Brook Watts from Louis Stokes Cleveland VA Medical Center in Ohio.
A 49-year-old man came to the clinic with a 1-week history of suprapubic pain and fever. On examination, he had a temperature of 38.1°C but appeared well. A urinalysis revealed numerous white cells, two red cells, and more than two bacteria per high-power field. A urinary tract infection was diagnosed, and oral gatifloxacin was prescribed.
The patient returned the following day, reporting an inability to urinate and he was discharged home with an indwelling urinary catheter and a prescription for oral doxazosin.
The patient's symptoms persisted and he returned 3 days later. CT of the abdomen and pelvis revealed an abscess in the right portion of the prostate gland. In addition, in the normal location of the spleen, contrast-enhanced CT showed a 4-cm soft-tissue density that was thought to be a hypoplastic or accessory spleen.
On admission, the patient reported new pruritic lesions on his arms, face, and trunk and pain in his right ankle. The patient worked as a long-distance bus driver. His normal routes were through the midwestern and northeastern United States.
The patient's condition declined and he was eventually intubated and placed on ventilatory support.
What could explain multiple nodular and pustular skin lesions, a prostatic abscess, mild fever, monoarticular joint involvement and subsequent physiologic decline? In this case, the correct diagnosis was reached only by building from the ground up, one clue at a time.

Blastomyces dermatitidis感染によるブラストミセス症。ミシシッピ川流域を侵淫する風土病。

The Drenched Doctor

A CLINICAL PROBLEM-SOLVING article by Daniel Kaul from University of Michigan Medical School in Ann Arbor.
A 55-year-old male physician was seen in August because of a 1-week history of fever and night sweats. The patient also noted a persistent cough, which had previously been ascribed to esophageal reflux.
Three months earlier, he had received empirical treatment with a 5-day course of clarithromycin for fever and cough, with initial resolution of the fever and improvement, but not resolution, of the cough. The chest radiograph at that time revealed no infiltrate. There were calcified nodules near the hilum of each lung and a densely calcified hilar lymph node which had been noted on chest radiographs over the previous 30 years and attributed to healed histoplasmosis.
Over the next week, the fever and cough continued, and the night sweats increased in severity, drenching the patient's sheets as well as his nightclothes. On several occasions, his temperature was 38.4°C or higher. He returned to his physician's office; an examination showed no abnormalities. The patient's white-cell count was now 3700 per cubic millimeter.
Five days later, the white-cell count was 7200.
He was treated with ciprofloxacin. The fever diminished, but the fever and night sweats returned after the course of medication had been completed. The cough worsened, and the patient reported that it was exacerbated by swallowing foods and liquids.
In this case, the recognition of the pivot point — coughing on swallowing — was required for the correct diagnosis.

A Hand-Carried Diagnosis

A CLINICAL PROBLEM-SOLVING article by Clinton Greenstone from Veterans Affairs Ann Arbor Medical Center, in Michigan.
A 34-year-old black woman presented to a walk-in clinic with a 3-day history of malaise. Her colleagues had noticed yellowing of her eyes over the past few days.
The patient said she had no fever, chills, sweats, nausea, vomiting, diarrhea, abdominal or chest pain, cough, or dyspnea. She had had one sexual partner for the previous 2 years, and her last sexual contact occurred 6 months earlier without barrier protection. She had taken Ortho-Novum, her only medication, for the previous 2 years, but she discontinued this medication 5 months earlier when she broke up with her last partner because of his infidelity.
On examination, her temperature was 38.0°C, blood pressure 110/78 mm Hg, and heart rate 100 beats per minute. Skin examination revealed no rash or spider angiomas. She had scleral icterus. On abdominal examination, she had mild tenderness on deep palpation in the right upper quadrant.
The patient's hepatic laboratory values showed a cholestatic injury pattern.
The patient was sent home and advised to rest and increase her fluid intake while awaiting the test results.
The patient returned to the clinic 3 days later. She now reported a new rash, which she described as having started on her abdomen and then spread to her legs, arms and palms.

手掌の薔薇疹が決め手となりました。肝炎などを呈したのは、梅毒が"the great imitator"と呼ばれる所以です。 the great imitatorに関しては、英語版wikipedia、Zebra Cardsに詳しい記載があります。

A Sinister Development

A CLINICAL PROBLEM-SOLVING article by Reza Fazel from Emory University in Atlanta, Georgia.
A 35-year-old woman presented to the emergency department with a 2-day history of progressive swelling and pain in her left leg, without antecedent trauma. She also reported mild dyspnea during the previous day, with no associated chest discomfort.
Six months earlier, she had given birth to a healthy infant by vaginal delivery at term; her pregnancy had been uncomplicated. Her only medications were oral contraceptives and a multivitamin.
In the emergency department, she was not in acute distress and was afebrile. Her left leg showed no evidence of trauma but there was considerable swelling extending from her ankle to the upper thigh, and the area of the swelling was markedly tender to palpation. The leg was slightly pale with diminished but palpable pulses.
Doppler ultrasonography of the veins in her left leg showed abnormally sluggish blood flow in the proximal deep venous system but was inconclusive for thrombus. A ventilation–perfusion scan of the lung was normal.
Intravenous unfractionated heparin was started, and the patient was hospitalized for further evaluation of the cause of pain and swelling in her left leg.

May-Thurner症候群、aka腸骨静脈圧迫症候群：左総腸骨静脈は右総腸骨動脈と交差して いますが、この交差する部分で腸骨静脈が腸骨動脈と背側にある椎体との間で圧排されることで血流障害が生じ、何らかの誘因で左下肢のDVTを引き起こすものです。左ということが肝で、タイトルの"sinister"には、「不遇な」と同時に「左の」という意味があります。

A Growing Problem

A CLINICAL PROBLEM-SOLVING article by Wendy Yeh from Brigham and Women's Hospital, Boston.
A 36-year-old pregnant woman at 21 weeks of gestation presented with a 4-week history of a dry, nonproductive cough.
She had no fever, chills, dyspnea, chest pain, or weight loss. It was her first pregnancy, and there were no complications. She had no new pets, environmental exposures, or sick contacts. In the past, she had traveled to Australia, Central Asia, and sub-Saharan Africa.
Her cough improved, but did not resolve, with the use of an inhaled bronchodilator. Her symptom persisted for another month, and she was started on an H2-blocker for empirical treatment of gastroesophageal reflux disease. She continued to use an H2-blocker for the remainder of her pregnancy. She had an uncomplicated vaginal delivery 4 months later. She continued to have intermittent dry cough and presented again 2 months after delivery for a reevaluation of her cough.
A chest radiograph revealed a soft-tissue mass, 7 cm in diameter, adjacent to the right heart border.
This patient had an uncommon cause of a common symptom.
This case illustrates the importance of not ignoring a growing problem, even if the presentation seems benign.

A Stitch in Time

A CLINICAL PROBLEM-SOLVING article by Christopher Graber from University of California at San Francisco.
A 64-year-old man with a history of coronary artery disease and peripheral vascular disease with an aortobifemoral bypass seventeen months before was admitted with a several-month history of fevers, chills, and fatigue. These symptoms had begun soon after he had undergone percutaneous coronary intervention with placement of a stent in the left anterior descending coronary artery. He had initially been treated empirically with a 5-day course of ciprofloxacin. However, the symptoms returned 1 week after discontinuation of the antibiotic, and 3 weeks later he was admitted to a hospital. Blood cultures obtained at that time were positive for group C streptococcus. He was discharged with instructions to complete 6 weeks of therapy with ceftriaxone.
1 month after finishing the antibiotics, he reported the recurrence of fatigue, malaise, and low-grade fever.
At the outset of the case, the lack of blood cultures before the patient received antibiotic therapy on multiple occasions clouded the clinician's ability to make the diagnosis. However, the history of recurrent low-grade fevers and malaise despite antibiotic therapy and eventual multiple, positive blood cultures prompted a strong clinical suspicion of an endovascular infection.

タイトルは、A stitch in time saves nine.（転ばぬ先の杖）の諺から。

Nothing to Cough At

A CLINICAL PROBLEM-SOLVING article by Paul Cornia from Veterans Affairs Puget Sound Health Care System in Seattle, Washington.
A 73-year-old man presented to the emergency department with a 4-day history of nonproductive cough that worsened at night. He did not have fever, nasal congestion, sore throat, hemoptysis, chest pain, or dyspnea.
The patient had a history of coronary-artery disease, hypertension, and possible aortic stenosis. He reported that none of his medications had been started recently. His vital sign was normal. A chest radiograph was normal.
The emergency department physician thought the patient's cough was probably related to the use of lisinopril and advised that the drug be replaced with an angiotensin-receptor blocker.
One week later, the patient returned to the clinic and reported that, despite the change in medication, the cough had worsened. It was present throughout the day but remained particularly bothersome at night and disrupted sleep.
Cough is one of the most common symptoms for which patients see their primary care physicians. The differential diagnosis for cough is broad and encompasses disorders that range from those that are relatively benign to those that are potentially life-threatening. The duration of cough at the time of presentation is a useful first step toward narrowing the differential diagnosis.
This case describes an important, but often overlooked, cause of cough.

coughは厄介だ。その名のジャーナルがあることからも察することができる。臨床的においてのみならず、語学的な意味においても、また厄介だ。

• [ɔ́ː] bought, brought, thought, fought, sought, nought, daughter, naughty...
• [óu] though, although, dough（３語）
• [uː] through（１語）
• [áu] bough, drought, plough（３語）
• [ou/ə] thórough, bórough（２語）
• [ʌ́f] enough, rough, tough（３語）
• [ɔ́(ː)f] cough, trough（２語）
• [ʌp] hiccough（１語）

No Respecter of Age

旬な感染症の話。「診断のゲシュタルトとデギュスタシオン 」にも取り上げられています。

A CLINICAL PROBLEM-SOLVING article by Don Martin from Johns Hopkins University School of Medicine, Baltimore, Maryland.
A previously healthy 65-year-old woman went to her primary care physician in late August, seeking evaluation of a “spot” that had appeared on her right leg 3 weeks earlier. Her physical examination was notable only for a low-grade temperature elevation and a 7-to-8-mm erythematous macule on her right leg.
One week later, the skin lesion had resolved, but the patient returned, reporting malaise and diffuse arthralgias that had progressively worsened, with intense, disabling pain and stiffness in her neck, shoulders, wrists, hands, knees, and ankles. In addition, she noted pain in the left anterior part of her chest that had awakened her from sleep, was exacerbated by respiration, and was partially relieved by sitting up.
She reported no recent contact with anyone who was sick and had last seen her grandchildren 6 weeks earlier.
The patient's constitutional symptoms and polyarticular involvement suggest the development of a systemic inflammatory arthritis. Although the initial skin lesion may have been unrelated to her subsequent symptoms, this history points to a possible infectious cause.
Bacterial, atypical, and viral infections can cause inflammatory arthritis, and arthritis can also follow infection with a variety of organisms.
As this case illustrates, the absence of known contact with someone who is sick does not rule out infection.

The Leading Diagnosis

A CLINICAL PROBLEM-SOLVING article by Thomas Baudendistel from California Pacific Medical Center in San Francisco.
A 23-year-old black woman presented to the emergency department with diffuse, colicky abdominal pain of 1 hour's duration. The pain was followed by nausea and episodes of bilious vomiting and did not radiate or change with the patient's position.
The patient reported that a similar episode had occurred 6 months previously. At that time, she passed red blood from the rectum once but did not seek medical attention.
On examination, she was restless and clutching her abdomen. Abdominal examination revealed hyperactive bowel sounds and a CT scan of the abdomen showed intussusception of a segment of small intestine.
On closer inspection, several small hyperpigmented lentigines were detected on the patient's fingers, tongue, and everted lips.

Failure to Respond

A CLINICAL PROBLEM-SOLVING article by Michael Ezzie from Ohio State University, Columbus.
A 52-year-old man presented to his primary care physician with dyspnea and cough. For the past 15 years, he had recurrent episodes of cough that were relieved only by intermittent courses of oral corticosteroids. He had been treated on three occasions during the past year with 20 mg of prednisone daily for 2 weeks. In the previous 3 weeks, his cough had increased in frequency, and severe dyspnea had developed. This time, 2 weeks of prednisone had not provided relief. He had occasional chills but no fever. His cough was productive of yellow sputum.
The patient's medical history included complete resection of a thymoma 5 years earlier.
The patient was admitted to the hospital. Chest X ray showed bilateral alveolar infiltrates.
The patient was started on moxifloxacin for community-acquired pneumonia. Gram's staining of a sputum specimen showed gram-positive diplococci with many leukocytes; two blood cultures grew penicillin-sensitive Streptococcus pneumoniae. The patient was switched to intravenous penicillin G but continued to be hypoxemic. Chest X ray showed no improvement after 5 days of therapy.
Clinical improvement with pneumococcal pneumonia is generally observed within 3 days after the initiation of appropriate therapy, and the limited improvement in the patient's condition was a concern.
When a patient's condition does not improve despite appropriate therapy, the clinician must reconsider the course of action. This requires critical appraisal of the original diagnosis and a thorough investigation of possible causes of treatment failure.

What's the Connection?

A CLINICAL PROBLEM-SOLVING article by Aharon Sareli from University of Pennsylvania, Philadelphia.
A 26-year-old man presented with 1-month history of persistent cough productive of white sputum, which was occasionally tinged with blood. He reported mild pleuritic chest pain. His cough had been treated with azithromycin with no resolution of his symptoms.
Five years before this presentation, the patient had been treated for a right-sided spontaneous pneumothorax. Three years before presentation, he was found to have a spontaneous left renal-artery dissection with renal infarction.
On present examination, the patient appeared comfortable and was in no acute distress. He had generalized joint hypermobility involving both small and large joints.
A chest radiograph revealed a left lower-lobe cavity with an air–liquid level, small left-sided apical pneumothorax, and left hydrothorax. Chest CT revealed subcentimeter nodules with surrounding haziness.
The patient received 14 days of intravenous ampicillin–sulbactam to treat a presumed lung abscess. Seventeen weeks later, the patient presented with massive hemoptysis.
In this case, both the discussant and the clinical team did what experienced diagnosticians often do when confronted with a patient whose illness does not lend itself to a simple diagnosis: try to find the connection between the present illness and past abnormalities.

In the Thick of It

A CLINICAL PROBLEM-SOLVING article by Deepak Rao from Brigham and Women's, Boston.
A 52-year-old man presented to the emergency department with an acute onset of palpitations and chest pressure. Two days earlier, epigastric burning, fatigue, weakness, and emesis had developed. On presentation, his heart rate was 200 beats per minute. An electrocardiogram showed an irregular rhythm with high-amplitude, mildly prolonged QRS complexes that were consistent with atrial fibrillation with a rapid ventricular response, left ventricular hypertrophy, and interventricular conduction delay. Intravenous fluids and intravenous metoprolol were given without effect, after which electrical cardioversion was performed and sinus rhythm was restored. He was transferred to a tertiary care hospital for further care.
The patient's medical history was notable for hypertension and renal dysfunction (cause unknown) and renal transplantation.
A transthoracic echocardiogram showed severe, concentric biventricular hypertrophy.
In this case, although the patient's history of hypertension offered a straightforward explanation for the observed hypertrophy, several aspects of his presentation were not consistent with hypertensive cardiomyopathy, including the presence of biventricular hypertrophy and preexcitation which suggested the presence of a metabolic storage disorder.

タイトルは、心筋の肥厚(thickness)と酣（たけなわ）の意のthickを掛けたのでしょうか。

対訳：ボストンの教訓

NEJMオンライン版に「ボストンの教訓」の俯瞰記事が寄せられている。その中で救急隊、医療者に味方した要因が挙げられており、ブログ「感染症診療の原則」でも取り上げられていたので、対訳の形でまとめてみた。

The bombing occurred at a major event where large numbers of police, security, and EMS personnel were already deployed.
爆発が起きた時に、既に多数の救急隊員や警備員・警察官がマラソンの為に待機していた。
Because it was race day — indeed, a state holiday — it is likely that the city's operating rooms and other clinical services were running at less than full capacity.
マラソンの日≒マサチューセッツ州の休日だった。このため病院が混雑してなかった。
The attack happened shortly before the 3 p.m. change of shift at area hospitals. As a result, a full complement of administrative staff and two shifts of health care providers were on site at each facility.
爆発が午後3時という病院の勤務交代の直前の時間に起こったので帰るチームとこれから働くチームの両者が病院に居た。
The bombs were detonated in a city that is home to seven trauma centers and multiple world-class hospitals. Boston EMS personnel wisely distributed casualties among the area's trauma centers, so each one received a manageable number.
ボストンという街自身が7ヶもの外傷治療センター、多数の世界のトップクラスの病院を持ち、更に救急隊員が賢明な布陣・分布体制をとっていたので必要なマンパワーがすぐに得られた。
The bombers detonated their relatively low-yield devices out-of-doors. A bombing inside a closed space (e.g., a building, bus, or train) produces more primary blast injuries (e.g., blast lung) and fatalities, because surrounding walls concentrate blast waves. The absence of structural collapse facilitated the swift extrication of victims.
爆弾の性能が悪かった　＆　建物の外で起きたので爆発の圧力が拡散された。（戸内であったらもっと惨状に・・）更に周辺の建物が崩壊せず救出しやすかった。
Although most health care providers in the United States have never treated a bombing victim, lessons learned by military surgeons, emergency physicians, and nurses in Iraq and Afghanistan are progressively percolating through the trauma care community.
外傷治療専門家の世界では、イラクやアフガニスタンで経験を積んだ軍の外科医や救急医が次第に全米各地に知識を広めていた。
Moreover, hundreds of Boston's prehospital and hospital-based responders had already learned the basics of blast-injury care and the operational challenges their city could face.
またボストンの医療従事者は爆弾の爆発による災害の対処法を既にまなんでいた。
In 2009, Rich Serino, then Boston's EMS chief and now deputy administrator of the Federal Emergency Management Agency, hosted the first citywide “Tale of Our Cities” conference in Boston, at which doctors from India, Spain, Israel, Britain, and Pakistan who had managed the consequences of terrorist attacks explained the nature of the blast injuries they treated, the triage systems they used, and other lessons responders can use to save lives. More than 750 locals attended.
事件の4年も前にボストンの救急の責任者で現在は連邦緊急事態管理庁（Federal Emergency Management Agency：FEMA）の副責任者のRich Serinoは既にテロ経験豊かなインド、パキスタン、スペイン、イギリスの専門家を集めて勉強会を開いていた。

今回に始まったことではありませんが、個人的な教訓は、ローカルで済んでいた都市伝説が世界的な規模で拡散するようになったことでしょうか。そう言えば、最近、ロケットニュースに、「Dカップ以上の大きなおっぱいを10分見つめると健康になれる」という記事が載りましたが、そうとう昔の、しかも、真っ赤な嘘です。

Original Publications

• Lessons from Boston via NEJM
• 同じ事が東京で起きたら・・ボストンの不幸中の幸い via 感染症診療の原則