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。