CASE 56: GENERALIZED ITCHING
History
A 63-year-old man presents to his general practitioner (GP) complaining that over the past
3 months he has developed severe generalized itching. This is particularly severe after a hot
bath. He has also noticed frequent headaches, dizziness and tinnitus. He has been hyper-
tensive for 10 years. He smokes 35 cigarettes a day and drinks about 25 units of alcohol per
week. He takes bendroflumethiazide for his hypertension. He works as a chef, is divorced
and lives alone.
Examination
His face looks plethoric. He has no rash. There are no signs of chronic liver disease and no
lymphadenopathy. His pulse is 84/min regular and blood pressure 162/104 mmHg. Exami-
nation of his heart and respiratory system is normal. In his abdomen the only abnormality
is that his spleen is palpable 4 cm below the left costal margin. Neurological examination
is normal.
NormalHaemoglobin 18.6 g/dL 13.3–17.7 g/dL
Mean corpuscular volume (MCV) 88 fL 80–99 fL
White cell count 14.2% 109 /L 3.9–10.6% 109 /L
Platelets 598 % 109 /L 150–440% 109 /L
Sodium 137 mmol/L 135–145 mmol/L
Potassium 4.6 mmol/L 3.5–5.0 mmol/L
Urea 6.4 mmol/L 2.5–6.7 mmol/L
Creatinine 84 &mol/L 70–120&mol/L
Bilirubin 12 mmol/L 3–17 mmol/L
Alanine transaminase 24 IU/L 5–35 IU/L
Alkaline phosphatase 68 IU/L 30–300 IU/LUrinalysis: no protein; no bloodINVESTIGATIONS
Questions
- What is the likely diagnosis?
- What are the major causes of generalized itching without a rash?
- How would you investigate and manage this patient?