31 IU/L (normal: 8-40 IU/L)

Gastrointestinal-#5 201211650 藤井辰賢
A 25-year old man presents to his physician with a complaint of “yellow eyes” for the past day. For the past five
days, he has been ill with a low-grade fever, rhinorrhea, myalgias, and generalized malaise. The physical
examination confirms scleral icterus, but is otherwise unremarkable. Electrolytes and complete blood cell count
are all within normal limit. Laboratory tests below:
Aspartate aminotransferase: 31 IU/L (normal: 8-40 IU/L)
Alanine aminotransferase: 25 IU/L (normal: 4-40 IU/L)
Alkaline phosphatase: 45 IU/L (normal: 120-320 IU/L)
Total bilirubin: 3 mg/dL (normal: 0.2-1.2 mg/dL)
Lactate dehydrogenase: 40 IU/L (normal: 124-232 IU/L)
Haptoglobin: 76 mg/dL (normal: 46-316 mg/dL)
His urinalysis demonstrates a normal bilirubin level. What is the most appropriate treatment for this patient’s
condition?
T ビリルビン上昇のみから考えられるのは＝①溶血性黄疸(autoimmune hemolytic anemia etc), ②肝細胞性黄
疸(ウイルス性肝炎, 肝硬変, 肝がん etc)、③閉塞性黄疸(胆石, 膵・胆菅癌 etc)、④肝内胆汁うっ滞(薬剤性肝障
害 etc), ⑤体質性黄疸(直接型)(Dubin-Johnson syndrome, Rotor syndrome) ⑥体質性黄疸(間接型)(Gilbert
syndrome, Criler-Najjar syndrome)
しかし、LDH の上昇がないので、①溶血性黄疸の可能性は↓。AST、ALT の値が正常値なので、②肝細胞性黄
疸の可能性は↓。ALP の上昇がないので、③閉塞性黄疸の可能性は↓。胆汁うっ滞所見(血清胆汁酸・胆道系酵
素・コレステロールの上昇)を認めるとは言いにくいので、④肝内胆汁うっ滞の可能性は↓。尿中ビリルビンの値
は正常なので、⑤体質性黄疸(直接型)の可能性は↓。従って、２５歳, 強膜黄疸以外の異常な身体所見なし, 血中
電解質と血算は正常, 尿中ビリルビンの値は正常という点から、⑥体質性黄疸(間接型)の Gilbert syndrome が疑
われる(Criler-Najjar syndrome の発症年齢は生後 1~3 日 (Criler-Najjar syndrome type 1) or 生後 1 年以内
(Criler-Najjar syndrome type 1)。Gilbert syndrome に対する治療は、
「必要なし」なので答えは(B)
(A) Corticosteroids
: Autoimmune hemolytic anemia の治療に使われる。
(B) No treatment is required
(C) Pegylated interferon
: 慢性 C 型肝炎の治療に使われる。
＊pegylate
: (biochemistry) To react with polyethylene glycol (PEG) with a protein such as interferon in order to
disguise its presence to the immune system.
＊pegylated interferon
: PEG is added to make interferon last longer in the body. They are used to treat hepatitis B, hepatitis C and
multiple sclerosis.
(D) Phenobarbital
: Criler-Najjar syndrome の治療に使われる。
(E) Ursodeoxycholic acid
: 胆石の治療に使われる。

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