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Why is this man itching all over?

GP Dr Oliver Starr describes how this patient’s yellow eyes led him to the right diagnosis

GP Dr Oliver Starr describes how this patient's yellow eyes led him to the right diagnosis

The patient

This 46-year-old man looked entirely well as he said: ‘I'm feeling itchy all over, doctor. It started on my hands but now it's driving me crazy.' Aside from this he was fine. He had seen our nurse about a year ago after a big toenail avulsion, but that was it.

When I examined him there was no rash to see anywhere.

I was about to say my usual ‘it'll settle, try Eurax' when I wondered if his eyes looked a touch yellow. He hadn't noticed, but I asked him to humour me with a blood test. It could have just been how his eyes normally looked; I wouldn't know as I had never met him before.

Differential diagnoses

• Haemolytic anaemia

• Choledocholithiasis

• A pancreatic lesion

• Systemic causes of pruritus.

Haemolytic anaemia can cause itchiness with a raised bilirubin and a drop in haemoglobin with a macrocytosis. If this had shown up I would have proceeded to a Coombs test and referred him to haematology.

Stones in the common bile duct escaping from the gallbladder were a distinct possibility. They do not always cause pain and usually show up on ultrasound. The jaundice and itching would fit with this.

A head of pancreas tumour was a differential, although he looked too well to have cancer. There was no weight or appetite loss, although I've just seen a man with advanced colon cancer who hadn't lost any weight.

We are always told in dermatology talks to investigate thyroid, renal and liver function in any itching, so I duly ticked all the boxes on the blood form.

Getting on the right track

His bloods showed a normal FBC, but a very high bilirubin and ALP. All other bloods were normal. I organised an urgent ultrasound, which showed a dilated common bile duct.

I referred him to gastroenterologists via the two-week wait rule.

They performed an ERCP, which identified a distal common bile-duct stricture.

A stent allowed bile to flow freely and his jaundice settled. We were none the wiser because brushings taken did not reveal malignant cells. A CT scan confirmed the ERCP findings and showed a lytic lesion in a rib with a soft-tissue mass around it. A myeloma screen and epithelial tumour markers were normal.

The consultants referred him to a tertiary centre where, a full three months after my original referral, a second ERCP allowed biopsies to be taken. They showed B-cell lymphoma of the germinal centre type. Having been offered sperm banking, he has now started chemotherapy under the care of our haematologists.

When I saw him last week he looked well, hadn't lost any weight and wasn't particularly jaundiced. I was glad I acted on a mere passing thought.

Dr Oliver Starr is a GP in Stevenage, Hertfordshire

Yellowed eyes Yellowed eyes

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