Do we know the most common misdiagnoses?

Bruno, Michael mbruno at PENNSTATEHEALTH.PSU.EDU
Tue Nov 6 17:21:22 UTC 2018


I diagnosed a totally unexpected case of pulmonary TB on a CXR obtained for "cough" just last week, in Hershey PA!  The doctor who ordered the CXR was just as surprised as I was, when I called to give him the results.  A lot more US people are taking exotic travel abroad, so the infectious disease problems of the developing world are no longer isolated there!

Mike
(Radiologist)



Sent: Tuesday, November 6, 2018 11:11 AM
To: IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG
Subject: Re: [IMPROVEDX] Do we know the most common misdiagnoses?

Good Morning Everyone:

To add emphasis to Dr. Mihaescu's admonition:

As a pathologist supporting interventional radiology with a cart doing immediate microscopic examinations of biopsy and FNA material, I have found there is an almost a 100% miss rate for TB when it presents as a cavitating mass.  This is understandable given the relative incidence/prevalence of lung cancer to TB.  However, the risks of a missed diagnosis are wider ranging than the probable need for a second procedure due to inappropriate handling of the first specimen.

A significant number of personnel involved in the procedure and in the accessioning/examination of the specimen are placed at risk not to mention other patients when the subject of the procedure needs post procedure hospitalization.  And, on rare occasion, the tissue reaction to the TB including large epithelioid histiocytes have been misdiagnosed as squamous cell carcinoma further complicating the situation.

So, although rather rare in the U.S., TB should always be brought up in the mind of the radiologist when certain types of lung lesions are identified.

Mark Gusack, M.D.
President
MANX Enterprises, Ltd.
304 521-1980

-----Original Message-----
From: Traian Mihaescu <traian at MIHAESCU.EU>
Sent: Tuesday, November 6, 2018 10:58 AM
To: IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG
Subject: Re: [IMPROVEDX] Do we know the most common misdiagnoses?

As you mention lung diseases misdiagnosis please remember TUBERCULOSIS!
It is one of the most prevalent infectious disease in the world and diagnostic errors seems to be common. In Romania one of the first sistematic reasearch about diagnostic errors was published in 1960

Bungeteanu G, Buzescu M. Erori de diagnostic in tuberculoza pulmonara, Ed Medicala, Bucuresti, 1960

Traian Mihaescu, MD

Clinic of Pulonary Disease
Iasi, Romania
Www.ispro.ro

On 2018-11-05 20:40, David Ryon wrote:
> I’ll chip in a first draft from Pulmonary and Critical Care. I’m not
> aware whether the question has been formally assessed; it fails a
> Google screening.  But as practicing pulmonologist we see these things
> frequently:
>
> 1. Pneumonia.  This is frequently missed, with radiographic findings
> attributed to other causes ( most frequently CHF), or it is
> overdiagnosed, when radiographic findings are actually old, or due to
> atelectasis, or to an uncommon lung condition such as fibrosis or
> sometimes even lung cancer. Many practitioners don’t realize that it’s
> normal for a very elderly patient to present pneumonia only having
> lethargy, without cough, fever, or leukocytosis. On the other hand,
> it’s often standard of care (such as it is in community medicine) for
> infiltrates to initially be treated as pneumonia, considering less
> common diagnosis after the infiltrate doesn’t clear.
>
> 2. Asthma. Not unusual for us to see a middle aged or elderly patient
> newly misdiagnosed as having asthma, which is a HE MOST PREVALENT
> INFECTIOUS DISEASEchronic disease that usually starts in childhood.  A
> new diagnosis of ‘asthma’ in an older person should raise alarm bells
> that something is being missed.
> Commonly, the condition was ‘bronchial asthma’, an acute state of
> wheezing during a bronchial illness that does not require chronic
> management, or it is COPD, once the history of smoking over 20 pack
> years comes out and spirometry is performed. But sometimes new onset
> wheezing in an elderly person is a sign of an endobronchial tumor,
> some other tracheobronchial obstruction, or uncommon conditions like
> vasculitis affecting the lungs, for example.
>
> 3. Pulmonary embolism (PE). This diagnosis still gets missed,
> particularly when confounding findings are present on CXR (leads to
> diagnosis of pneumonia and early closure). PE is a recognized cause of
> persistent exacerbation od COPD symptoms. Finally, PE is normally
> discounted when a patient is supposedly anticoagulated, but I recently
> had a patient nearly go to comfort measures only because she was on
> warfarin when she presented with dyspneadoc and wedge-shaped
> peripheral infiltrates in setting of known metastatic breast cancer.
> Her large PE was clearly visible on a standard contrast CT done
> earlier in her admission, for unresolving ‘pneumonia’ that turned out
> to be pulmonary infarction.
>
> 4. COPD. We periodically see smokers who were heuristically handed
> this diagnosis when they complained of dyspnea, but turn out to have
> normal spirometry. Then they are found to have dyspnea for other
> reasons, such as coronary artery disease or other heart condition,
> most commonly, though there are about a dozen differential diagnosis
> categories. Occasionally such patients present with MI.
>
> 5. Lung cancer. This diagnosis completely dominates all other cancers
> in global mortality, in part because its onset is insidious, avoiding
> detection. Several traps here: with CXRs are no longer advised
> annually or pre-op and seemingly discouraged, providers can forget
> that the onset of cough in their smoker isn’t always just another COPD
> exacerbation, putting off the study, sometimes for months. Early
> tumors, and sometimes poorly located larger tumors do not show up on
> CXR. These people will need a CT scan for diagnosis, and persistent
> symptoms to justify the scan.  For heavy smokers, or those who quit in
> the past 15 years, annual Low Dose CT screening has been proven to
> catch a significant percentage of lung cancers early enough to make a
> survival difference. However, most offices don’t have processes for
> ensuring that their smokers actually get screened.  There are
> ‘breathalizer’ type screening devices being developed, which should
> help. Then there is the problem of following up results appropriately,
> and sadly, we rarely have the  ‘incidental’ discovery of a small lung
> nodule that became  incurable before the patient was notified. Most
> practices do not have an airtight process to prevent this tragedy.
> More details here:
> https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5338577/#
>
> Next: misdiagnosis in Critical Care.
> Thanks for putting up with my long post, it’s a privilege to be
> here....
>
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