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函館稜北病院総合診療科抄読会B面

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。

Treating Before Knowing

"Rare manifestations of common diseases are more common than common manifestations of rare diseases."という箴言を地で行くケースでした。"empiric therapy"という言葉があるくらい日常診療では、"Treating Before Knowing" は日常的なことではありますが、予想される疾患の magnitude、probability、costのいずれを重視するかで、戦略も変わってきますね。

【参加人数】4名

【今回の語数】2613語【累計語数】31,090語

【私の読了にかかった時間】16分32秒 (158 wpm)

【クリニカルパール】

  • As the patient's clinical course evolved, the first suggestion that he had postinfectious glomerulonephritis arose when serologic studies revealed a normal C4 level while C3 levels were low — evidence for activation of the alternative complement pathway. That pattern suggests acute post-streptococcal or membranoproliferative glomerulonephritis.

  • 上記の参考文献7から孫引きです。

Analysis of the complement cascade can be helpful in distinguishing between the two types of glomerulonephritis before biopsy. First of all, in contrast to the transient (three- to eight-week) decline in patients with acute poststreptococcal glomerulonephritis (alternative complement pathway activation), the level of C3 often remains depressed in patients with Type II membranoproliferative glomerulonephritis (also alternative complement pathway activation). Secondly, C3 nephritic factor can frequently be found in the serum of patients with membranoproliferative disease (Type I ≅ 33 per cent, Type II ≅ 75 per cent).9 Finally, the early components of the complement system (C1, C4, and C2) may be markedly depressed in Type I membranoproliferative disease (classic complement pathway activation) in contrast to the normal or slightly depressed levels of these components in Type II disease and acute poststreptococcal glomerulonephritis.

【感想】

  • cut to the chase とか、raise the specter of とか、かっこいい表現がありました。

  • 後知恵バイアスでしたが、咽頭所見はどうだったのか?ということから、喉頭蓋炎の話や耳鼻科、眼科的診察のことに話が広がりました。