Differential Diagnosis

The patient's symptoms of intermittent seeking and darkness around eyes worse in the morning, deep shin itching worse at night, and easy bruising can be approached by considering various potential diagnoses. Here's a categorized differential diagnosis:

• Single Most Likely Diagnosis

  • Vitamin Deficiency (B12 or Iron): The combination of symptoms such as intermittent blurred vision or darkness around the eyes (which could be related to visual disturbances), deep shin itching (possibly related to restless legs syndrome, which is associated with iron deficiency), and easy bruising (which could be due to a lack of platelet production or function, potentially related to B12 deficiency) points towards a nutritional deficiency. Both B12 and iron deficiencies can cause a range of systemic symptoms including neurological, dermatological, and hematological manifestations.

• Other Likely Diagnoses

  • Anemia: Easy bruising and possibly the visual disturbances could be related to anemia, which can cause fatigue, weakness, and shortness of breath, among other symptoms. The itching, especially if it's related to dry skin, could also be seen in the context of anemia.
  • Renal Disease: Itching (pruritus) is a common symptom in patients with chronic kidney disease, and anemia is also prevalent in this population, which could explain the easy bruising.
  • Liver Disease: Certain liver conditions can lead to easy bruising due to coagulopathy and itching due to bile salts buildup in the skin.

• Do Not Miss Diagnoses

  • Leukemia or Lymphoma: These conditions can cause easy bruising due to bone marrow suppression or infiltration, leading to cytopenias, including thrombocytopenia. Nighttime itching can be a symptom of some lymphomas.
  • Hodgkin Lymphoma: Specifically, this condition is known to cause severe itching (pruritus) without a rash, which can be worse at night.
  • Multiple Myeloma: This plasma cell disorder can cause anemia, renal failure (leading to itching), and bone lesions, which might indirectly contribute to the symptoms described.

• Rare Diagnoses

  • Polycythemia Vera: A myeloproliferative disorder that can cause itching (especially after warm baths), easy bruising, and possibly visual disturbances due to increased blood viscosity.
  • Mastocytosis: A condition characterized by the accumulation of mast cells in one or more organs, which can cause a range of symptoms including itching, easy bruising, and possibly visual disturbances due to mast cell degranulation effects.

Each of these diagnoses requires careful consideration of the patient's full clinical picture, including laboratory tests and potentially imaging studies, to accurately diagnose and manage their condition.