The MEDLINE Search as a Diagnostic Maneuver

[Dr.Vad]

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The MEDLINE Search as a Diagnostic Maneuver

One criticism that has been leveled at evidence-based medicine is that it can be applied well to populations of patients but may fail when it encounters the vagaries and variations of individual patients. In her fine commentary, Schattner addresses this criticism with her argument that the MEDLINE search can become, in essence, a powerful diagnostic maneuver for individual patients with complex, puzzling problems. In 3 of the 5 cases Schattner presents (fever of unknown origin due to aortic dissection; cytomegalovirus colitis complicating ulcerative colitis; and Sjögren syndrome with neutropenia and positive rheumatoid factor), the patient workups were either at a standstill or headed in wrong and potentially harmful directions until a literature search was performed.

Recently, an 82-year-old man was admitted to our inpatient service for weight loss and fatigue. In the course of his workup, multiple bilateral lung nodules were noted on his chest radiograph and computed tomographic scan, which were consistent with metastatic cancer. The only abnormal physical examination finding was a hard, nodular prostate. The prostate-specific antigen level was markedly elevated at 200 ng/mL. Bone scintigraphy results were negative, and there was no evidence of liver or pelvic metastases on abdominal computed tomography. Biopsy results of the prostate confirmed adenocarcinoma.

I had never seen or heard of prostate cancer with metastasis only to the lungs and consulted a pulmonologist for bronchoscopic biopsy to rule out a second malignancy. I also dispatched our medical student to do a literature search. He returned in a half hour with several case reports of prostate cancer metastatic only to the lungs, as well as one in which the pulmonary nodules regressed completely with antiandrogen treatment. After discussion with the patient, the pulmonologist, and theoncologist, the bronchoscopy was canceled and the patient was started on hormonal therapy.

I have often complained (and heard other attending physicians complain) that medical students and residents spend more time on the computer than at the bedside with their patients. I am beginning to understand, however, that the keyboard and the mouse are powerful diagnostic tools in their own right.

AUTHOR INFORMATION

Correspondence: Dr Packer, Firm B Clinic, Louis Stokes Cleveland VA Medical Center, 10701 East Blvd, Cleveland, OH 44106

Arch Intern Med. 2005 Mar 28;165(6):703-4.

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Simple Is Beautiful
The Neglected Power of Simple Tests


Arch Intern Med. 2004;164:2198-2200.

INTRODUCTION

Difficult diagnoses are a common challenge for primary care and hospital physicians alike. Physicians often respond to these cases by ordering an extensive battery of tests and imaging studies. Results may be diagnostic, but sometimes leading clues are overlooked or considered unimportant; and often, incidental findings beget more unnecessary testing. This process is not only costly and time-consuming but may actually endanger the patient. The following case histories emphasize an alternative approach.

1. A 60-year-old man with a persistent low-grade fever and a bicuspid aortic valve was evaluated for possible infective endocarditis. Since the results of blood and serologic tests, blood cultures, and transesophageal echocardiography were normal, endocarditis was ruled out, and an extensive search was continued. Only 6 months later, a simple question by a medical student about animal contact revealed that the patient, who had initially denied owning pets, was regularly feeding cats in his backyard. The association between cat exposure and culture-negative endocarditis was immediately made, even though only about 100 such cases had been reported at that time. Bartonella henselae serologic findings were strongly positive, as were those from a second echocardiogram. Despite treatment with antibiotics, the patient’s aortic valve had to be replaced.

2. A previously healthy 48-year-old farmer presented with weight loss, fever of unknown origin (FUO), and left-sided low back pain. Examination and imaging findings were inconclusive (including from skeletal radiographs, a bone scan, abdominal and chest computed tomograms, an ultrasound, and a gastrointestinal tract series). Attention was concentrated on a 2-cm right adrenal mass, which finally proved to be incidental. The back pain was forgotten. Blood tests showed an intense acute-phase activation, but extensive investigations failed to reveal its cause. At last, a positive gallium 67 scan, selected for its usefulness in the diagnosis of FUO, directed attention back to the left lower paravertebral muscles, where a primary lymphoma of the muscle (stage IE) was identified by biopsy6 and treated successfully by excision and chemotherapy.

3. A 66-year-old man with hypertension was admitted with a 2-month history of fever, night sweats, weight loss, and pain of low intensity in the left scapular region. Workup findings were positive only for a marked acute-phase response (erythrocyte sedimentation rate, 100 mm/h; normocytic anemia; and hyperglobulinemia) and a small left pleural effusion, which was tapped and found to be exudate. A thorough investigation for infectious, inflammatory, and neoplastic causes (including transthoracic echocardiogram) was inconclusive. However, in a textbook devoted to the differential diagnosis of pain, a discussion was found on dissecting aortic aneurysm as an uncommon but important cause of left scapular pain. Then, a Medline search uncovered articles on the possible presentation of aortic dissection as FUO ("FUO and aortic dissection," 5 articles identified in 1965-1966, 2 in English). Aortic dissection may also cause a left pleural effusion. A magnetic resonance imaging study of the chest was immediately performed, and the findings confirmed the diagnosis. The patient was treated conservatively, and the symptoms disappeared over time.

4. A young woman with ulcerative colitis had intractable bloody diarrhea resistant to all therapy. Only hours before total colectomy was scheduled, an intern presented the case to the Department of Medicine staff and discussed it. She mentioned a Medline citation that described patients with cytomegalovirus colitis that mimicked or was superimposed on ulcerative colitis.10 The colectomy was canceled, and the patient underwent an immediate colonoscopy with biopsies. Cytomegalovirus was indeed identified, and specific treatment was administered resulting in complete remission.

5. A 77-year-old woman presented with marked fatigue, night sweats, and weight loss. Physical examination was inconclusive, and blood tests showed a white blood cell count of 1.7 x 103/uL with 10% neutrophils, mild normocytic anemia, and an erythrocyte sedimentation rate of 85 mm/h. Bone marrow was reactive, and extensive evaluation failed to uncover any underlying disease to explain her symptoms and the agranulocytosis. Antinuclear antibodies were positively detectable at low titer, and rheumatoid factor (296 U; normal, <20 U) was also persistently detectable. A literature search indicated that this finding in the absence of rheumatoid arthritis, cryoglobulinemia, or infective endocarditis was consistent with primary Sjoegren syndrome. Informed directed questioning of the patient revealed the presence of dry mouth and dry eyes. She had not mentioned these symptoms previously: a review of systems with the patient had failed to elicit reports of these symptoms. Results from a Schirmer test and Rose-Bengall corneal staining were positive, and analysis of a minor salivary gland biopsy specimen confirmed Sjögren syndrome. Treatment with prednisone led to a resolution of her symptoms and amelioration of the neutropenia.

AUTHOR INFORMATION

Correspondence: Dr Schattner, Department of Medicine, Kaplan Medical Center, PO Box 1, Rehovot 76100, Hebrew University–Hadassah Medical School, Jerusalem, Israel

Arch Intern Med. 2004;164:2198-2200.