Case 1：A 53-year-old woman present to her primary care physician for a follow-up visit after having high blood pressure on her last visit. She is again found to be hypertensive and is prescribed hydralazine, a β-blocker, and furosemide. The woman takes no additional prescription or over-the-counter medications. She complains of muscle aches, joint pain, and rash. Physical exam reveals a temperature of 37.7℃ and a scaling erythematous rash on her face. The physician orders an autoantibody panel that yields the following results:
Antinuclear antibodies (ANA): Positive
Anti-ribonucleic protein (RNP) antibodies: Negative
Anti-Smith (Sm) antibodies: Negative
Anti-DNA antibodies: Negative
Anti-histone antibodies: Positive
Rheumatoid factor: Negative
案例1：一名53歲高血壓女性，現正向她的保健醫生求診。她服藥過程中再次出現高血壓，目前服用肼苯噠嗪、β-blocker和速尿。該患者沒有服用額外的處方或非處方藥物。主訴肌肉疼痛、關節痛和皮疹。查體體溫37.7℃，面部有鱗屑性紅疹。自身抗體檢測結果如下:
抗核抗體(ANA):陽性
抗核糖核酸蛋白(RNP)抗體:陰性
抗史密斯(Sm)抗體:陰性
Anti-DNA抗體:陰性
Anti-組蛋白抗體:陽性
類風溼因子:陰性
1 What is the most likely diagnosis and risk factors?
Rash, arthralgias and antihistone antibodies suggest drug-induced systemic lupus erythematosus (SLE). Hydralazine is the causative drug in this case. ANA+ is nonspecific since most infection and antoimmune diseases show ANA+. However, for drug-induced SLE, the sensitivity is 100%.
藥物性狼瘡
診斷特點：近期服藥史+突發麵部皮疹+關節痛+抗組蛋白抗體陽性→提示藥物性狼瘡。
特異性指標：ANA+雖無特異性，但藥物性狼瘡中ANA敏感性100%，陰性即可排除本診斷。
2 What other medications can cause a similar presentation?
Drugs known to induce SLE include chlorpromazine, isoniazid, methyldopa, minocycline, and diltiazem.
其他引起狼瘡樣表現的藥物：主要常見常用的有氯丙嗪、異煙肼、二甲胺四環素類和地西泮等。
3 How do spontaneous forms of this disorder differ from drug-induced forms?
Whereas hematologic abnormalities (anemia) are common in spontaneous SLE, they are unusual in drug-induced SLE. Also, rash is common in spontaneous SLE but is not frequent in drug-induced case.
鑑別診斷（與自發性SLE）：貧血+皮疹→多為自發SLE，藥物性狼瘡貧血罕見，皮疹少見。
Case 2: A 3-year-old boy is brought to the ER department by his grandmother who states that she saw the boy playing around old paint cans in the basement. For the past several days she has noticed that his appetite has decreased and he has indicted that his tummy hurts.
案例2：一名3歲的男孩被他的祖母帶到急診室，訴男孩在地下室的舊油漆罐周圍玩耍。在過去的幾天裡，患童食慾下降伴腹疼。
1 What is the most likely diagnosis?
Subacute lead poisoning. Abdominal colic is one of the hallmark symptoms of lead poisoning and can be followed by bloody diarrhea.
亞急性鉛中毒
診斷：題幹中兒童+油漆罐+腹痛→典型亞急性鉛中毒表現，標誌性特點為腹部絞痛，嚴重者可伴血便。
2 If the smear of this patient’s blood were examined, what signs would help confirm the diagnosis?
Basophilic stippling of erythrocytes is commonly seen with lead poisoning. In addition, lead poisoning may present in the form of sideroblastic anemia.
血塗片診斷：可見典型的紅細胞嗜鹼性點彩樣顆粒，此外也可表現為鐵幼粒紅細胞性貧血。
3 What neurologic complicaitons can occur in this condition?
Lead poisoning may present with neurological symptoms, inluding hearing loss, neuropathies and developmental delay. Tow often seen neuropathies are wrist and foot drop.
鉛中毒主要神經症狀：可致聽力喪失、發育遲緩和神經病變。典型表現：腕關節、踝關節下垂。
4 How does the treatment differ between children and adults with this condition?
Succimer is a water-soluble analog of dimercaprol and can be used treat children with lead poisoning as it increases the excretion of lead. For adults, the first-line treatment is EDTA and dimercaprol.
治療措施：兒童→二巰基丁二酸，促進鉛排洩；成人→EDTA+二巰基丙醇