毎週木曜日5:30PMから30分間、Clinical Problem-Solvingを素材にクリニカル・パールを拾い集めます。

第38回:"Against the Grain"


Word Count:2633語 (Time:  18'36'', 142 wpm)



  • Celiac disease is an autoimmune disorder that affects the small bowel and that is triggered by ingested gluten from barley, rye, and wheat..
  • Celiac disease is also manifested outside the gastrointestinal tract. Rashes (e.g., dermatitis herpetiformis), arthralgias, neurologic and psychiatric symptoms, fatigue, and infertility can be presenting manifestations.
  • The diagnosis is usually made on the basis of serologic screening, followed by a confirmatory small-bowel biopsy. The serologic test of choice is the IgA anti–tissue transglutaminase antibody assay, which is highly standardized, specific (94%), and sensitive (97%).


  • 直球ケースでした。でも、有名な割には、診たことがなく、日本人での疫学は、どうなんでしょう?
  • ジェローム・グループマン著「医者は現場でどう考えるか」は、何を食べても吐き出してしまう症状に苦しむ30代の女性のケースで始まる。15年に渡り30人近い医師の診療を受けながら、「摂食障害」と見なされてきたが、先入観抜きで彼女の「物語」に耳を傾けた医師がセリアック病を診断し、彼女を救う。いかに人間が認知バイアスから抜け出すことが難しいかを示す好例である。
  • セリアック病の名前が紛らわしい。(→「coeliac という単語はギリシャ語: κοιλιακος, koiliakos(腹部の)に由来しており、古代ギリシャにて本疾患を記述したとされるカッパドキアのアレタイオスの著作の翻訳に基づき、19世紀に導入された」らしい。)
  • 肝心の検査が日本ではコマーシャルベースではないので、疑ったら、GFDを指導して、治療的診断ということになりそう。麺類、パン、ビール、醤油…を除去なんて、つらい。
  • "Celiac Disease: Ten Things That Every Gastroenterologist Should Know" に要点がまとまっている。
  • ある資料によると、皮膚病変は、「肘、膝、臀部、肩、頭皮の伸筋領域に対称的に分布する強いかゆみを伴う丘疹小水疱性発疹である疱疹状皮膚炎を起こす。」とのこと。

第37回:"Just a Cut"


Word Count:2792語 (Time:  18'03'', 155 wpm)



  • The patient’s examination is very troubling, with all four Kanavel signs for infectious flexor tenosynovitis: flexor-sheath tenderness, circumferential swelling (a “sausage digit”), pain with passive stretch, and flexed posture.
  • In cases involving seawater exposure with rapidly progressive infection or evidence of systemic involvement, vibrio species must be considered. Other waterborne infectious agents are much less likely to manifest the fulminant features that were seen in this case. Vibrio is a gram-negative rod that is typically found in warm saltwaters, although it has been isolated in waters as cold as 17°C.
  • V. vulnificus infections can rapidly become fatal, progressing from an initial presentation of cellulitis, tenosynovitis, or necrotizing fasciitis to septicemia and death within 48 to 72 hours.


  • 上肢切断者の現状と動向 一 近畿地区におけるアンケート調査から一」という論文によると、上肢の切断の原因疾患として感染は2%を占めるに過ぎない。確かに多くはないが、自分の患者として巡り合う可能性はゼロではないことも確か。
  • セレンディピティというか、先日参加したICD講習会において二人の演者がともにこの感染症について言及していた。「軽い蜂窩織炎のように見えて、自覚症状がひどく痛がるというギャップが特徴」と話されていた。
  • NEJMのResident 360でも、パールがまとめられている。裏返すと、レジデントでも知って置くべき知識なのかもしれない。

第36回:"A Chilly Fever"

悪寒戦慄,悪心,重度の頭痛を伴う発熱が 1 週間続いた 30 歳の男性の症例で、結論は「マラリア」でした。

Word Count:2792語 (Time:  16'20'', 171 wpm)



  • In 2010, a total of 1691 cases were reported to the Centers for Disease Control and Prevention (CDC), the largest number reported since 1980; P. falciparum, P. vivax, P. malariae, and P. ovale were identified in 58%, 19%, 2%, and 2% of cases, respectively.
  • Given the patient's delayed presentation, years after presumed exposure, P. falciparum can be ruled out, since it does not give rise to relapses.
  • Primaquine, the only effective drug against dormant hypnozoites, has not been approved by the Food and Drug Administration for primary prophylaxis, but the CDC endorses its use for prophylaxis in Latin American countries where P. vivax predominates, because the drug can prevent both primary attacks and relapses caused by all species that are a source of malarial infection.
  • P. falciparum is resistant to chloroquine in most regions in which it is endemic and resistant to mefloquine in parts of Southeast Asia. In contrast, nonfalciparum malaria parasites do not have substantial resistance to mefloquine, and the distribution of chloroquine-resistant P. vivax malaria is limited, occurring primarily in Indonesia and Papua New Guinea.
  • This patient's travel to Uganda merits consideration for infections that can be acquired in East Africa and are manifested long after acquisition. These diseases include malaria, tuberculosis, filariasis (although this infection is unlikely after short-term travel), visceral leishmaniasis, and Q fever. Malaria relapses are more likely to begin with rigors than are primary infections. The physical examination should focus on the liver and spleen (since hepatosplenomegaly can develop in association with malaria, visceral leishmaniasis, or Q fever), the lungs (particularly the upper lobe, which is often involved in tuberculosis), the heart (since pericardial rubs or murmurs can be detected in association with Q fever), and the extremities and the scrotum (since lymphangitis and lymphedema can develop in association with filarial fevers).
  • In malaria, the febrile pattern is initially irregular but subsequently regularizes if a dominant brood of synchronously replicating parasites develops. Typically, the periodicity of fever is 72 hours with P. malariae and 48 hours with other species.
  • The average time to relapse is approximately 9 months, but it can range from weeks to years.


  • 旅行医学の分野では、まず除外すべき疾患だが、日本ではリソースの乏しさから診断の遅れが危惧される。(かえって途上国のほうがリソースが揃っているかもしれない。)
  • 温暖化が進めば、沖縄、九州あたりで復興するかもしれない。
  • 「研修医当直御法度」では、chillの程度を「 mild chills: 寒気:上着を羽織りたくなるくらい 、moderate chills: 悪寒:分厚い毛布を羽織りたくなるくらい 、shaking chills: 悪寒戦慄:分厚い毛布を羽織っていても全身が震えるくらい」と定義している。

第35回:"D Is for Delay"

Diarrhea, Dermatitis, Dementia, Deathの4つのDで要約される疾患だが、Deathの前に診断のDelayがあるでしょうということをタイトルは指摘しています。診断のDelayはある意味、裕福な社会の副作用かもしれません。同シリーズの "Remembering the ABC's" でも指摘されていますが。

Word Count:2735語 (Time:  17'36'', 155 wpm)



  • The absence of impaired vibration sense or proprioception makes diseases of the large, myelinated nerve fibers or dorsal column less likely.
  • The absence of hyperreflexia, increased tone, sensory level, and distal motor weakness argues against a compressive myelopathy.
  • Testing for cryoglobulinemia involves challenging logistics in terms of handling and processing the sample, so a false negative result is possible.
  • The dermatitis of pellagra involves sun-exposed skin in a bilateral and symmetric pattern.
  • One of the hallmark clinical signs is an eruption on the front of the neck extending into the region of cervical dermatomes C3 and C4, simulating a necklace (Casal's necklace).
  • The classic symptoms and signs of niacin deficiency typically evolve at different intervals over time, rather than appearing simultaneously, making it harder for the clinician to see the pattern and apply diagnostic parsimony.
  • However, once there is diagnostic momentum (the tendency for a particular diagnosis to become established over time across multiple providers without adequate evidence or verification), reframing the situation in each new encounter becomes more challenging, and previous solutions (in this case, antibiotic treatment for recurrent episodes of presumed cellulitis) become engrained.
  • Patients with pellagra should also receive a high-protein diet and B-complex vitamins, since they frequently are malnourished and have other vitamin deficiencies.


  • 徘徊の英語表現は、wanderingとか、walking aloneとか言う。さらに無目的性を強調したければ、aimlessを加える。
  • ビタミンB3、C3領域の皮疹、D3の症状。




Medical Journal of Australia


オープンデータ(2):Healthcare Hack with Open data (H2O)





第34回:"Testing Limits"


Word Count:2262語 (Time:  15'15'', 148 wpm)



  • Protracted constitutional symptoms, weight loss, the lack of response to antibiotics, negative blood cultures, and the increasing ESR suggest noninfectious causes.
  • Vasculitides, such as giant-cell arteritis, can be associated with fevers and may explain dry cough and weight loss; the absence of headache, visual symptoms, or jaw claudication does not rule out this diagnosis.
  • The overall survival rate at 5 years is 51% among women with localized uterine leiomyosarcoma and 5% among those with metastatic leiomyosarcoma.


  • 読みが浅いのか、ちょっと退屈な症例。新しい物がいいとは限らない好例か。
  • "Jaw claudication" から、Benzodiazepine Withdrawal Syndrome の話へ展開、きっと臨床医はみな「アシュトン・マニュアル」(日本語版[pdf])に目を通しておいたほうがいいでしょう。
  • なにか気がついたことがあれば、"To the Editor" に投稿するといいかも。アクセプトされれば、病院のいい宣伝になりますね。