Masahito Miyahara

Positron emission tomography findings in a patient with multiple myeloma of polymyalgia rheumatica-like symptoms caused by paraneoplastic syndrome

A 50-year-old Japanese man was referred to our department with pain in his limb joints persisting for 3 months. Although his joints showed no redness, swelling or tenderness, he had a limited range of motion of his hip and shoulder joints, suggesting a diagnosis of polymyalgia rheumatica (PMR). However, his relatively young age and subacute course along with the absence of morning stiffness made the diagnosis uncertain. We performed positron emission tomography/CT, which revealed 18F-fluorodeoxyglucose uptake in bilateral upper and lower joints, consistent with PMR. There was also uptake by a sacral tumour, suggesting a diagnosis of paraneoplastic syndrome. Immunoglobulin A-κ type M protein was detected in serum and bone marrow aspiration/biopsy identified diffuse proliferation of atypical plasma cells, confirming a diagnosis of multiple myeloma. The patient received chemotherapy, which alleviated his limb pain, and achieved stringent complete remission after autologous peripheral blood stem cell transplantation.

Influence of predicting the diagnosis from history on the accuracy of physical examination

Background This study aimed to clarify the influence of predicting a correct diagnosis from the history on physical examination by comparing the diagnostic accuracy of auscultation with and without clinical information. Methods The participants were 102 medical students from the 2013 clinical clerkship course. Auscultation was performed with a cardiology patient simulator. Participants were randomly assigned to two groups. Each group listened to a different simulated heart murmur and then made a diagnosis without clinical information. Next, a history suggesting a different murmur was provided to each group and they predicted the diagnosis. Finally, the students listened to a murmur corresponding to the history provided and again made a diagnosis. Correct and incorrect diagnosis rates of auscultation were compared between students with and without clinical information, between students predicting a correct or incorrect diagnosis from the history (correct and incorrect prediction groups, respectively), and between students without clinical information and those making an incorrect prediction. Results For auscultation with or without clinical information, the correct diagnosis rate was 62.7% (128/204 participants) versus 54.4% (111/204 participants), showing no significant difference (P=0.09). After receiving clinical information, a correct diagnosis was made by 102/117 students (87.2%) in the correct prediction group versus 26/87 students (29.9%) in the incorrect prediction group, showing a significant difference (P=0.006). The correct diagnosis rate was also significantly lower in the incorrect prediction group than when the students performed auscultation without clinical information (54.4% versus 29.9%, P<0.001). Conclusion Obtaining a history alone does not improve the diagnostic accuracy of physical examination. However, accurately predicting the diagnosis from the history is associated with higher diagnostic accuracy of physical examination, while incorrect prediction is associated with lower diagnostic accuracy of examination.

Unilateral lower abdominal wall protrusion and umbilical deviation

Postherpetic pseudohernia must be suspected when a patient develops motor dysfunction coincident with or following a herpes zoster eruption.

Idiopathic segmental anhidrosis

A 32-year-old man presented with a 2-year history of left hemifacial hyperhidrosis induced by exercise or hot environments. He reported episodes of heat intolerance and anhidrosis over the right side of his face. His past medical history was unremarkable. Physical examination revealed no evidence of a somatic neurological deficit or autonomic failure. Laboratory data, chest contrast computed tomography and cervical magnetic resonance imaging showed no abnormalities. Thermography revealed that the right facial surface temperature was higher in the anhidrotic area (red) than in the sweating area (yellow to blue) (Figure 1). Idiopathic segmental anhidrosis (ISA) was diagnosed. Idiopathic anhidrosis is classified into acquired idiopathic generalized anhidrosis and segmental anhidrosis. Segmental anhidrosis includes Ross syndrome, Harlequin syndrome and ISA. ISA is characterized by the absence of other obvious neurological symptoms, and is considered as an abortive form of Ross’ syndrome (tonic pupil, hyporeflexia, and segmental anhidrosis), although its etiology remains unclear.

Paraganglioma-induced alveolar hemorrhage.

A 21-year-old man twice developed sudden dyspnea during running examinations for promotion. Chest computed tomography (CT) revealed lobular ground-glass opacity and centrilobular shadows bilaterally. The bronchoscopy findings were consistent with alveolar hemorrhage, and echocardiography showed severe hypokinesia a few hours later. A mass was subsequently identified along the abdominal aorta on enhanced CT and iodine-131 metaiodobenzylguanidine scintigraphy. Catecholamine oversecretion, which was later confirmed, may have increased the pulmonary vein pressure, thus resulting in the development of an alveolar hemorrhage, and damaged the cardiac muscles as manifested by hypokinesia. Since the patient had not previously developed alveolar hemorrhage during usual exercise, emotional stress superimposed on the physical activity may have triggered the paraganglioma to secrete excessive catecholamines, thus resulting in the observed symptoms.

Accuracy of diagnoses predicted from a simple patient questionnaire stratified by the duration of general ambulatory training: an observational study.

Purpose To compare the diagnostic accuracy of diseases predicted from patient responses to a simple questionnaire completed prior to examination by doctors with different levels of ambulatory training in general medicine. Participants and methods Before patient examination, five trained physicians, four short-term-trained residents, and four untrained residents examined patient responses to a simple questionnaire and then indicated, in rank order according to their subjective confidence level, the diseases they predicted. Final diagnosis was subsequently determined from hospital records by mentor physicians 3 months after the first patient visit. Predicted diseases and final diagnoses were codified using the International Classification of Diseases version 10. A “correct” diagnosis was one where the predicted disease matched the final diagnosis code. Results A total of 148 patient questionnaires were evaluated. The Herfindahl index was 0.024, indicating a high degree of diversity in final diagnoses. The proportion of correct diagnoses was high in the trained group (96 of 148, 65%; residual analysis, 4.4) and low in the untrained group (56 of 148, 38%; residual analysis, −3.6) (χ2=22.27, P<0.001). In cases of correct diagnosis, the cumulative number of correct diagnoses showed almost no improvement, even when doctors in the three groups predicted ≥4 diseases. Conclusion Doctors who completed ambulatory training in general medicine while treating a diverse range of diseases accurately predicted diagnosis in 65% of cases from limited written information provided by a simple patient questionnaire, which proved useful for diagnosis. The study also suggests that up to three differential diagnoses are appropriate for diagnostic prediction, while ≥4 differential diagnoses barely improved the diagnostic accuracy, regardless of doctors’ competence in general medicine. If doctors can become able to predict the final diagnosis from limited information, the correct diagnostic outcome may improve and save further consultation hours.