Generalized Pruritus

[DrQuinn]

---

Members don't see this ad.

I know most of you know this, but thought this was kinda cool.

70ish year lady relatively healthy had 12 hours of generalized itching. Hx only of arthritis. ROS otherwise negative. no weight loss. hyperpigmented sclera (my patients are almost all AA). no change in stools. appetite good. no palmar erythema. She looked absolutely amazing.

Vital signs normal. No recent travel. Had taken 2-3 T3s within the past week for her arthritis which is nothing normal.

By my HPI above you can see where I was headed but just want to let you stew about it for a bit.

Don't miss this in generalized pruritus!
Q

 

[WilcoWorld]

PBS or PSC?

 

[southerndoc]

What was her bilirubin?

 

[DrQuinn]

What was her bilirubin?

Exactly. This is the only test that I ordered that I cared about. Her UA came back with + Bili and +urobilinogen, and I knew I had it. Her Tbili was 7, and scanned her abdomen and found a pancreatic mass. Literally her ROS was ALL negative except for "I've been itching for the past day."

Her sclera was hyperpigmented and pretty hard to discern any jaundice, and I even asked her if her eyes were different, which she denied. I looked under her tongue but I have never been one to find it that helpful, and no i'm not colorlbind.

Anywho, I think this is the second patient I have had in "fast track" with "generalized itching" that I've dx with a pancreatic mass.

Emergent? no. Urgent? Maybe. But not something I'd like to miss.

Q

 

[southerndoc]

Fluorescent lights make it difficult to detect jaundice, scleral icterus, etc. People often forget to use a halogen light (such as the otoscope light) to look for it.

 

[colforbinMD]

Normal amyl/lipase?

 

[mlw47]

Pardon my ignorance, but can someone please go over the pathophysiology of this? I'm just a medical student and I can't find an explanation for this in Basic Robbins or after a quick google-ing.

 

[gutonc]

Pardon my ignorance, but can someone please go over the pathophysiology of this? I'm just a medical student and I can't find an explanation for this in Basic Robbins or after a quick google-ing.

That pathophys of which, the jaundice or the pruritis?

Jaundice from CBD block
Pruritis from elevated bili - it's itchy

 

[mlw47]

The pruritis.

Thanks!

That pathophys of which, the jaundice or the pruritis?

Jaundice from CBD block
Pruritis from elevated bili - it's itchy

 

[GBotDO]

The pruritis.

Thanks!

Bile salts deposit in skin = irritation.

 

[dilatate]

What about AML? Mostly just after hot showers in the text books, but that might be a rare presentation (from the increased mast cells-->degranulation). Obviously, hyperbili regardless of cause is more common by several orders of magnitude, but just a thought.

 

[mlw47]

Polycythemia vera by mast cell degranulation too. The excess histamine would also cause GI upset, but that doesn't seem to be a problem here. Gout too.

What about AML? Mostly just after hot showers in the text books, but that might be a rare presentation (from the increased mast cells-->degranulation). Obviously, hyperbili regardless of cause is more common by several orders of magnitude, but just a thought.