Dissociation and misdiagnosis of schizophrenia in populations experiencing chronic discrimination and social defeat

As recently as the late 20th century, Schizophrenia, a category of mental illness with widely varying phenotypic symptoms, was believed by psychobiologists to be a genetically based disorder in which the environment played a limited etiological role. Yet a growing body of evidence indicates a strong correlation between schizophrenia and environmental factors. This theoretical paper explores the relationship between highly elevated rates of schizophrenia in some low-income minority communities worldwide and trauma-related dissociative symptoms that often mimic schizophrenia. Elevated rates of schizophrenia in racially and ethnically isolated, inner-city Black populations are well documented. This paper contains evidence proposing that this amplification in the rate of schizophrenia is mediated by childhood trauma, disorganized attachment, and social defeat. Further, evidence demonstrating how these three variables combine in early childhood to incubate dissociative disorders will also be conveyed. The misdiagnosis of dissociative disorders as schizophrenia is theorized to partially mediate the increased rate of schizophrenia in communities that experience high levels of racial/ethnic discrimination. It is argued that this misdiagnosis is often attributable to cultural misunderstanding and/or a lack of knowledge about dissociative disorders.

Misdiagnosis of eosinophilic cystitis: A case report and literature review

RATIONALE

Eosinophilic cystitis (EC) is a rare and specific transmural inflammatory disease in clinic. At present, its etiology is unknown, its clinical manifestations are diverse, and its auxiliary examination lacks specificity, so it is easy to be missed or misdiagnosed in clinical practice.

PATIENT CONCERNS

A 72-year-old male patient with symptoms of lower urinary tract obstruction accompanied by hematuria was diagnosed with benign prostatic hyperplasia with bleeding by B-ultrasound and urinary CT examination. After being treated with catheterization, anti-infection and hemostasis, he was selectively treated with transurethral resection of prostate, but he saw a pattern mass on the right back wall of the bladder during the operation. Considering bladder tumor, he removed the lesion and gave pirarubicin for bladder perfusion. However, the postoperative pathological result was EC.

DIAGNOSIS

The diagnosis of EC can only rely on pathological examination, and the accurate and positive rate of biopsy can be improved by obtaining muscle tissue as much as possible at the same time of multi-point biopsy.

INTERVENTION

Prednisone and cetirizine were given orally after transurethral resection of lesions, and tamsulosin and finasteride were given regularly to treat benign prostatic hyperplasia.

OUTCOMES

No recurrence and abnormal urination were found during the follow-up for half a year, and the upper urinary tract function was normal.

LESSONS

The clinical manifestations of EC are atypical, the laboratory examination and imaging examination are not specific, and it is difficult to make a definite diagnosis before operation. The diagnosis depends on pathological examination. Transurethral resection of the lesion can obviously improve the positive rate of biopsy while completely removing the lesion, and the combined drug treatment can achieve satisfactory results in a short period of time. Active follow-up after operation is very important to identify the recurrence of the disease and prevent the upper urinary tract function from being damaged.

Painless Orbital Bone Infarction in a Child with Sickle Cell Anemia: A Case of Misdiagnosed Periorbital Cellulitis

BACKGROUND Sickle cell orbitopathy is a rare complication of sickle cell disease that closely mimics other conditions, such as orbital cellulitis and osteomyelitis. We report a case of painless orbital bone infarction masquerading as periorbital cellulitis in a child with sickle cell anemia. CASE REPORT A 4-year-old Saudi girl with sickle cell disease presented to our hospital with vaso-occlusive crisis characterized by bilateral lower limb pain and painless left orbital swelling. On examination, she had swelling of the left upper eyelid with redness and mild ptosis (margin reflex distance 1 was 2 mm) without proptosis. Magnetic resonance imaging with contrast showed bilateral sub-periosteal heterogeneous collections (2×0.8×2.1 cm in the superolateral wall of the left orbit and 1×0.6 cm in the inferolateral wall of the right orbit), with intermediate-to-high T1 signal intensity and high T2 signal, causing a mass effect on the adjacent superior and lateral rectus muscles. The patient was treated with systemic antibiotics and supportive treatment for vaso-occlusive crisis under the care of the pediatric team and was discharged without complications. CONCLUSIONS The diagnosis of sickle cell orbitopathy can be challenging, and an accurate diagnosis is essential to ensure appropriate management. Thus, we report the case of a 4-year-old child with painless sickle cell orbitopathy masquerading as pre-septal cellulitis.

Paraneoplastic pemphigus misdiagnosed as juvenile dermatomyositis: A case report

Paraneoplastic pemphigus (PNP) is a rare autoimmune skin disease closely related to tumors, characterized by a maculopapular rash with mucosal pain, bronchiole occlusion, and respiratory failure may occur over time, even resulting in death. We report a rare case of a child with autoimmune PNP misdiagnosed as juvenile dermatomyositis (JDM), and summarize the key points of differentiation of clinical manifestations and auxiliary examinations of PNP and JDM. When the diagnosis is not clear because the patient has features not typical of JDM, then skin biopsy and other diagnostic studies should be considered prior to any immunosuppressive therapy, as this could potentially obscure and delay the diagnosis of malignancy.

About uterine enhanced myometrial vascularity: Doppler ultrasound could reduce misdiagnosed life-threatening vaginal bleeding after pregnancy and guide the management

Enhanced myometrial vascularity is a rare entity in which an abnormal communication between vessels of the myometrial wall, potentially derived from all pregnancies, increases bleeding risk. Spontaneous regression is possible, but often, it is not foreseeable in which cases it's better to adopt a waiting behaviour and in which others a treatment is required. We reported three cases of enhanced myometrial vascularity: two occurring after vaginal delivery, and the third one after a scar pregnancy. The first case was successfully treated by embolization, the second one was subjected to curettage complicated by uterine perforation; the third one underwent embolization as well, but subsequently required hysterctomy for persistent methrorragia. As we treated these similar cases in three different ways, we decided to perform a mini review of the literature in the aftermath. Considering literature data, we strongly believe that the detection of peak systolic speed by colour-Doppler ultrasound together with a careful evaluation of clinical symptoms, could be a good guide to the best treatment of each patient.

Patent foramen ovale-associated stroke repeatedly misdiagnosed as cerebral small vessel disease: A case report

BACKGROUND

Transthoracic echocardiography (TTE) is the most commonly used screening method for cardiac structural abnormalities. However, it may lead to a missed diagnosis of partial patent foramen ovale (PFO)-associated stroke.

CASE PRESENTATION

A 60-year-old male was admitted to the hospital for recurrent left limb weakness with or without slurred speech for 14 months. No stroke-related cardiac structural abnormality was detected during repeated TTE, and the patient was diagnosed with cerebral small vessel disease. Finally, right-to-left shunt was detected by contrast-enhanced transcranial Doppler. Subsequently, the patient was diagnosed with PFO-associated stroke by transesophageal echocardiography and contrast transesophageal echocardiography.

CONCLUSIONS

TTE has a low detection rate of PFO, such that it is easily missed. Contrast-enhanced transcranial Doppler is easy to operate and should be promoted as a supplementary measure to stroke etiological investigation and primary PFO screening.

Two Cases with 17-alpha Hydroxylase Deficiency Misdiagnosed as Primary Aldosteronism

AIM

Lack of CYP17A1 prevents sex steroid biosynthesis, yielding a female phenotype in 46, XY males and sexual infantilism in both sexes; overproduction of 11-deoxycorticosterone (DOC) in the zona fasciculata typically causes mineralocorticoid hypertension. In this study, we report two cases of severe hypokalemia, hyperaldosteronism, and sexual infantilism.

CASE PRESENTATION

Case 1 admitted severe hypertension and hypokalemia with female external genitalia with 46, XY. The patient also had right adrenal masses of 35*30 mm diameters. Case 2 was presented with delayed pubertal development with 46, XX genotype. In addition, she had severe hypertension and hypokalemia with nodular surrenal hyperplasia in her abdomen imaging.

METHODS

Further hormonal and biochemical results were followed as elevated adrenocorticotropic hormone (ACTH) levels, low serum cortisol, 17 hydroxy progesterone (17 OHP) and dehydroepiandrosterone sulphate (DHESO4) and estradiol (E2) levels in both cases.

RESULTS

Genetical analyses confirmed 17 OHP deficiency in both cases.

CONCLUSION

The condition of patients with 17 alpha-hydroxylase deficiency may substantially resemble primary hyperaldosteronism and must be considered in patients as primary hypogonadism (and) associated with mineralocorticoid hypertension.

Misdiagnosis and Mistreatment of a Rare Case of Intracranial Oncogenic Osteomalacia with an Altered Amino Acid Profile

Background. Oncogenic osteomalacia (OO), also known as tumor-induced osteomalacia (TIO), is a rare paraneoplastic syndrome caused by mesechymal tumors secreting fibroblast growth factor 23 (FGF23). Common in middle age, these tumors are often disclosed by progressive generalized bone pain and muscle weakness, along with an altered biochemical profile. Despite its characteristic presentation, the disease is often underrecognized with delayed onset of surgical or pharmacological intervention that can have serious repercussions on the patients' health and quality of life. Case presentation. We describe the case of a 65-year-old Caucasian man presenting TIO with intracranial and spinal localizations and Fanconi-like aminoaciduria. The condition was misdiagnosed and mistreated for three years, leading to loss of self-sufficiency and depression. Following proper identification, the spinal mass was excised with complete remission of the functional symptoms. As it was not possible to remove the intracranial lesion, the patient was treated conservatively with calcitriol and phosphorous supplements that granted good metabolic control up to the time of a recent follow-up visit (at 5 years). Conclusions. The finding of an altered amino acid profile, not usually reported in these cases, should prompt clinicians to a wider usage of these molecules as suitable candidates for metabolic diseases. In addition to providing central information, they are easy to obtain and inexpensive to analyze. Such determination could help to speed up the diagnostic process, as a long-lasting history of misdiagnosis and mistreatments can lead primarily to clinical worsening, but also to the use of expensive, useless medications with side effects that contribute to poor patient health.

Perimedullary arteriovenous fistula was misdiagnosed as intervertebral disc herniation: A case report

INTRODUCTION

Spinal perimedullary arteriovenous fistula (PMAVFS) is a rare intradural vascular malformation with a high rate of misdiagnosis. In adults, most spinal PMAVFs are small and low-flow, starting with progressive spinal dysfunction.

PATIENT CONCERNS

The patient was a 58-year-old male who presented with both lower limbs numb with intermittent walking weakness, obvious at both ankles, and no obvious inducing and relieving factors. The local hospital considered the diagnosis of lumbar disc herniation after MR examination; he was treated with lumbar fixation and fusion.

DIAGNOSIS

After admission, a ce-MRA examination showed that the left spinal artery at the T10 level showed small branch blood vessels in the local area. The distal end was unclear, which seemed to be connected with the drainage vein of the spinal cord. The digital subtraction angiography (DSA) result indicated that the left intercostal artery of T10 sent the Adamkiewicz artery down to the level of L4, and an arteriovenous fistula was seen. The fistula was located at the lower edge of the L4 level and then drained to the upper premedullary vein to the level of T4 after a short descending. It was finally diagnosed as a perimedullary arteriovenous fistula.

INTERVENTIONS

It was cured by cutting the arteriovenous fistula in the spinal canal by indocyanine green-assisted angiography.

OUTCOMES

we report a case of PMAVFS misdiagnosed as lumbar disc herniation with resection and internal fixation. In our hospital, the final diagnosis was a perimedullary arteriovenous fistula, which was cured by cutting off the arteriovenous fistula within the spinal canthus.

CONCLUSION

Spinal perimedullary arteriovenous fistula (PMAVFS) is a rare intradural vascular malformation with a high rate of misdiagnosis. In adults, most spinal PMAVFs are small and low-flow, starting with progressive spinal dysfunction. It is hoped that this can provide warnings to more neurosurgeons and reduce the occurrence of misdiagnosis.

Solitary Rectal Ulcer Syndrome: A Rare and Often Misdiagnosed Cause of Rectal Bleeding in Children

Solitary rectal ulcer syndrome (SRUS) is an uncommon benign rectal disorder. Typically, young adults are affected and it is rare in children. Straining during defecation, self-induced trauma and paradoxical contraction of puborectalis muscle are the major contributing factors of this condition. Clinical features of SRUS are rectal bleeding, mucorrhoea, excessive straining during defecation, tenesmus, feeling of incomplete defecation and constipation. A complete and thorough history is most important for diagnosis of SRUS. Rectal bleeding may be misinterpreted as originating from an anal fissure caused by constipation or as other causes of rectal bleeding such as a juvenile polyp. The best and most accurate diagnostic method of SRUS is rectal biopsy. The major histological feature of SRUS is fibromuscular obliteration of the lamina propria. Avoiding straining, regular toilet habit, use of bulk laxatives, steroid and sucralfate enemas are the mainstay of treatment. Biofeedback mechanism is another treatment option. Because the clinical presentation varies, the diagnosis requires a high index of suspicion for both the clinician and the pathologist.

Russula subnigricans Poisoning Causes Severe Rhabdomyolysis That Could be Misdiagnosed as Non-ST Segment Elevation Myocardial Infarction

Mushroom poisoning and subsequently the number of patients visiting emergency rooms are increasing, as well as the proportion of fatal mushroom poisonings. Myocytic mushroom poisoning is one of the new clinical classifications. This report documents the course of a family with Russula subnigricans poisoning complicated by severe rhabdomyolysis, including a case that was misdiagnosed as myocardial infarction. A 64-y-old man visited our hospital with symptoms including substernal chest discomfort, nausea, vomiting, and myalgia, lasting for 12 h. His laboratory tests showed elevated serum high-sensitive troponin I. He was diagnosed with non-ST segment elevation myocardial infarction. After that, 2 family members who ate mushrooms together were transferred from a local emergency room with the diagnosis of rhabdomyolysis. Consequently, rhabdomyolysis due to mushroom poisoning was diagnosed. They were hospitalized in the intensive care unit. After admission, conservative management, including primary fluid resuscitation, was performed, and the patients were discharged without complications. R subnigricans poisoning was revealed after investigation and should be considered in mushroom poisoning with rhabdomyolysis. Early recognition and intensive supportive care are important for mushroom poisoning patients.

Bilateral Optic Nerve Head Drusen Complicated by Choroidal Neovascularization Misdiagnosed as Papilledema and Neuroretinitis

We report a case of bilateral optic nerve head drusen complicated by choroidal neovascularization (CNV) in the left eye at presentation. The presence of optic disc and macular edema in addition to exudation led to the misdiagnosis of neuroretinitis at an outside medical center. Swept-source optical coherence tomography (SS-OCT) and SSOCT angiography were critical in establishing the diagnosis and follow-up in a noninvasive manner. Secondary CNV associated with optic nerve head drusen responded well to intravitreal injections of anti-vascular endothelial growth factor in the left eye. Asymptomatic nonexudative CNV that developed in the right eye during follow-up regressed spontaneously without treatment. [Ophthalmic Surg Lasers Imaging Retina 2022;53:518-521.].

Progressive Multifocal Leukoencephalopathy Misdiagnosed as Neuropsychiatric Systemic Lupus Erythematosus With a Catastrophic Outcome

INTRODUCTION

Progressive multifocal leukoencephalopathy (PML) is a rare infection of the central nervous system due to the reactivation of the John Cunningham polyomavirus. It is commonly a progressive fatal disease with worldwide distribution.

CASE REPORT

We describe a rare case of PML, which was misdiagnosed as neuropsychiatric systemic lupus erythematosus (SLE) with a catastrophic outcome due to delay in diagnosis with superadded cyclophosphamide therapy.

CONCLUSION

There are several lessons taught from our case. Firstly, in patients with autoimmune disorders who are strongly immunosuppressed, the new onset of cognitive impairment and seizures should alert the treating physician to look carefully for PML. Secondly, in cases of SLE where the diagnosis of the cause of cognitive impairment and seizures is not clear, we suggest that immunosuppression should not be intensified until PML has clearly been ruled out. Lastly, multidisciplinary care in patients with suspected neuropsychiatric SLE including a neurologist, an infectious diseases consultant, a neuroradiologist, and a rheumatologist is needed.

Angiographically Occult Subarachnoid Hemorrhage: Yield of Repeat Angiography, Influence of Initial CT Bleed Pattern, and Sources of Diagnostic Error in 242 Consecutive Patients

BACKGROUND AND PURPOSE

Nearly 20% of patients with spontaneous SAH have no definitive source on initial DSA. The purpose of this study was to investigate the timing and yield of repeat DSA, to clarify the influence of initial CT bleed pattern, and to characterize sources of diagnostic error in this scenario.

MATERIALS AND METHODS

We evaluated the yield of repeat DSA and clinical outcomes stratified by hemorrhage pattern on CT in consecutive patients with nontraumatic SAH with negative initial DSA findings at a referral center. Cases in which the culprit lesion was subsequently diagnosed were classified as physiologically occult (ie, undetectable) on the initial DSA, despite adequate technique and interpretation or misdiagnosed due to operator-dependent error.

RESULTS

Two hundred forty-two of 1163 (20.8%) patients with spontaneous SAH had negative initial DSA findings between 2009 and 2018. The SAH CT pattern was nonperimesencephalic (41%), perimesencephalic (36%), sulcal (18%), and CT-negative (5%). Repeat DSA in 135/242 patients (55.8%) revealed a source in 10 patients (7.4%): 4 saccular aneurysms, 4 atypical aneurysms, and 2 arteriovenous shunts. The overall yield of repeat DSA was 11.3% with nonperimesencephalic and 2.2% for perimesencephalic patterns. The yield of the second and third DSAs with a nonperimesencephalic pattern was 7.7% and 12%, respectively. Physiologically occult lesions accounted for 6/242 (2.5%) and operator-dependent errors accounted for 7/242 (2.9%) of all angiographically occult lesions on the first DSA.

CONCLUSIONS

Atypical aneurysms and small arteriovenous shunts are important causes of SAH negative on angiography. Improving DSAs technique can modestly reduce the need for repeat DSA; however, a small fraction of SAH sources remain occult despite adequate technique. These findings support the practice of repeating DSA in patients with a nonperimesencephalic SAH pattern.

A Patient with Acute Abdominal Pain Caused by an Unnoticed Swallowed Toothpick Misdiagnosed as Acute Appendicitis

The differential diagnosis of acute abdominal pain is a challenging task for medical doctors working in the department of gastroenterology. It is clear that acute abdominal pain may be associated with a number of pathologic conditions. We report an unusual case of an unnoticed swallowed wooden toothpick stuck in the ileocecal area of a young man with right lower abdominal pain who was misdiagnosed as acute appendicitis. However, an abdominal computed tomography scan showed an elongated foreign body stuck in the ileocecal area. The elongated foreign body was identified as a wooden toothpick, which was then grasped with a foreign body forceps and successfully removed through colonoscopy. The patient's abdominal pain was significantly relieved within 2 days following treatment. On the basis of the case report, we suggest the importance of abdominal computed tomography scans for the differential diagnosis of acute abdominal pain and highlight the need for extra vigilance in excluding the diagnosis of foreign bodies in the gastrointestinal tract of patients with acute abdominal pain.

Fishbone-induced Pericardial Hemorrhage Resulting in a Misdiagnosis of Acute Myocardial Infarction

Fishbone intake is a common clinical event; but serious complications resulting from the ingestion of fishbones, such as perforations in the stomach, diaphragm, and pericardium and heart lacerations, are rare. Here, we present a case of fishbone-induced pericardial hemorrhage that led to a misdiagnosis of acute myocardial infarction (AMI) since the emergency coronary angiogram showed normal coronaries. However, the patient's circulatory status was not good and an echocardiogram revealed pericardial effusion. A contrast-enhanced computed tomography (CT) of the chest and abdomen showed a foreign body in the upper abdomen. Therefore, an urgent exploratory thoracotomy was performed, and it was discovered that the pericardial hemorrhage was caused by the fishbone puncturing the pericardium and myocardium of the right ventricle. The fishbone was removed, damaged vessels were repaired, and the pericardium was closed with a drain. The patient was discharged in good clinical condition. In order to avoid unnecessary damage and suffering, the possibility of a foreign body in the esophagus or heart must be considered when patients have chest pain, and careful reporting of histories and corresponding examinations are necessary.    Key Words: Acute myocardial infarction, Fishbone, Pericardial effusion.

[Misdiagnosis of Acute Renal Artery Thrombosis as Acute Abdominal Disease:Report of One Case]

Renal artery thrombosis can cause acute occlusion of unilateral or bilateral renal arteries,and kidney failure would be induced if it is not diagnosed and treated in time.Therefore,rapid and correct treatment is especially important for renal artery thrombosis.Due to the lack of specificity of clinical manifestations,this disease in commonly misdiagnosed or missed and thus has a low early diagnosis rate.Here we report a case of acute renal artery thrombosis to improve the diagnosis and treatment.

Crown-rump length measurement error: impact on assessment of growth

OBJECTIVE

To examine the impact of first-trimester crown-rump length (CRL) measurement error on the interpretation of estimated fetal weight (EFW) and classification of fetuses as small-, large- or appropriate-for-gestational age on subsequent growth scans.

METHODS

We examined the effects of errors of ± 2, ± 3 and ± 4 mm in the measurement of fetal CRL on percentiles of EFW at 20, 32 and 36 weeks' gestation and classification as small-, large- or appropriate-for-gestational age. Published data on CRL measurement error were used to determine variation present in practice.

RESULTS

A measurement error of -2 mm in first-trimester CRL shifts an EFW on the 10^th percentile at the 20-week scan to around the 20^th percentile, and the effect of a CRL measurement error of + 2 mm would shift an EFW on the 10^th percentile to around the 5^th percentile. At 32 weeks, a first-trimester CRL measurement error would shift an EFW on the 10^th percentile to the 7^th (+ 2 mm) or 14^th (-2 mm) percentile; at 36 weeks, the EFW would shift from the 10^th percentile to the 8^th (+ 2 mm) or 12^th (-2 mm) percentile. Published data suggest that measurement errors of 2 mm or more are common in practice.

CONCLUSION

Because of the widespread and potentially severe consequences of CRL measurement errors as small as 2 mm on clinical assessment, patient management and research results, there is a need to increase awareness of the impact of CRL measurement error and to reduce measurement error variation through standardization and quality control. © 2021 International Society of Ultrasound in Obstetrics and Gynecology.

[Inguinal hernia in children: easily incarcerated]

Inguinal hernia in children is caused by an incomplete obliteration of the vaginal process during the embryological development. The vaginal process can thus become a hernia sac that often contains bowel and in girls, an ovary. The diagnosis of inguinal hernia is made by history and physical examination. According to current guidelines surgical repair should be performed without delay to avoid incarceration, which gives a high risk of complications, including testicular atrophy and ischemia of vital organs. However, patients are regularly not referred adequately. We present three cases of children who developed complications of a non-repaired inguinal hernia. Additionally, the data of all children with a congenital inguinal hernia, surgically treated from January 2018 until August 2019 show that out of 243 children 13.6% presented acutely with an incarcerated inguinal hernia. Another 6% received a wrong advice from their primary care doctor and was not referred to a (pediatric) surgeon.

Prognostic impact of misdiagnosis of cardiac channelopathies as epilepsy

INTRODUCTION

Cardiac channelopathies are a frequent cause of sudden cardiac death (SCD) and often manifest with convulsive syncope, leading to a misdiagnosis of epilepsy. We aim to evaluate the clinical impact of epilepsy misdiagnosis in a cohort of patients with cardiac channelopathies.

METHODS

Fifty probands/families with a cardiac channelopathy were included. We retrospectively collected information from medical records to identify all patients who presented with convulsive syncope and were diagnosed with epilepsy after neurological evaluation. Clinical data and outcome were compared with those of patients without a previous epilepsy diagnosis.

RESULTS

Eight patients had a previous diagnosis of epilepsy. At first episode, 3 of them presented a positive family history of SCD and 5 showed a pathological electrocardiogram; half presented with sudden cardiac arrest (SCA) and the rest with recurrent syncope despite treatment with 1 or more anti-epileptic drugs. Five patients had long QT syndrome, 2 had catecholaminergic polymorphic ventricular tachycardia, and 1 had Brugada syndrome. Epilepsy misdiagnosis was associated with an increased risk of SCA/SCD (OR 6.92, P = .04), a delay of 12 years (P = .047) in correct diagnosis, and a delay from first symptom to channelopathy diagnosis of 18.45 years (P < .0001).

CONCLUSION

Cardiac channelopathy patients can be misdiagnosed with epilepsy. This involves a delayed diagnosis, a delay from the first symptom to a correct diagnosis, and an increased risk of SCA/SCD.

Regret among primary care physicians: a survey of diagnostic decisions

BACKGROUND

Experienced and anticipated regret influence physicians' decision-making. In medicine, diagnostic decisions and diagnostic errors can have a severe impact on both patients and physicians. Little empirical research exists on regret experienced by physicians when they make diagnostic decisions in primary care that later prove inappropriate or incorrect. The aim of this study was to explore the experience of regret following diagnostic decisions in primary care.

METHODS

In this qualitative study, we used an online questionnaire on a sample of German primary care physicians. We asked participants to report on cases in which the final diagnosis differed from their original opinion, and in which treatment was at the very least delayed, possibly resulting in harm to the patient. We asked about original and final diagnoses, illness trajectories, and the reactions of other physicians, patients and relatives. We used thematic analysis to assess the data, supported by MAXQDA 11 and Microsoft Excel 2016.

RESULTS

29 GPs described one case each (14 female/15 male patients, aged 1.5-80 years, response rate < 1%). In 26 of 29 cases, the final diagnosis was more serious than the original diagnosis. In two cases, the diagnoses were equally serious, and in one case less serious. Clinical trajectories and the reactions of patients and relatives differed widely. Although only one third of cases involved preventable harm to patients, the vast majority (27 of 29) of physicians expressed deep feelings of regret.

CONCLUSION

Even if harm to patients is unavoidable, regret following diagnostic decisions can be devastating for clinicians, making them 'second victims'. Procedures and tools are needed to analyse cases involving undesirable diagnostic events, so that 'true' diagnostic errors, in which harm could have been prevented, can be distinguished from others. Further studies should also explore how physicians can be supported in dealing with such events in order to prevent them from practicing defensive medicine.

Impact of biometric measurement error on identification of small- and large-for-gestational-age fetuses

OBJECTIVES

First, to obtain measurement-error models for biometric measurements of fetal abdominal circumference (AC), head circumference (HC) and femur length (FL), and, second, to examine the impact of biometric measurement error on sonographic estimated fetal weight (EFW) and its effect on the prediction of small- (SGA) and large- (LGA) for-gestational-age fetuses with EFW < 10^th and > 90^th percentile, respectively.

METHODS

Measurement error standard deviations for fetal AC, HC and FL were obtained from a previous large study on fetal biometry utilizing a standardized measurement protocol and both qualitative and quantitative quality-control monitoring. Typical combinations of AC, HC and FL that gave EFW on the 10^th and 90^th percentiles were determined. A Monte-Carlo simulation study was carried out to examine the effect of measurement error on the classification of fetuses as having EFW above or below the 10^th and 90^th percentiles.

RESULTS

Errors were assumed to follow a Gaussian distribution with a mean of 0 mm and SDs, obtained from a previous well-conducted study, of 6.93 mm for AC, 5.15 mm for HC and 1.38 mm for FL. Assuming errors according to such distributions, when the 10^th and 90^th percentiles are used to screen for SGA and LGA fetuses, respectively, the detection rates would be 78.0% at false-positive rates of 4.7%. If the cut-offs were relaxed to the 30^th and 70^th percentiles, the detection rates would increase to 98.2%, but at false-positive rates of 24.2%. Assuming half of the spread in the error distribution, using the 10^th and 90^th percentiles to screen for SGA and LGA fetuses, respectively, the detection rates would be 86.6% at false-positive rates of 2.3%. If the cut-offs were relaxed to the 15^th and 85^th percentiles, respectively, the detection rates would increase to 97.0% and the false-positive rates would increase to 6.3%.

CONCLUSIONS

Measurement error in fetal biometry causes substantial error in EFW, resulting in misclassification of SGA and LGA fetuses. The extent to which improvement can be achieved through effective quality assurance remains to be seen but, as a first step, it is important for practitioners to understand how biometric measurement error impacts the prediction of SGA and LGA fetuses. © 2019 The Authors. Ultrasound in Obstetrics & Gynecology published by John Wiley & Sons Ltd on behalf of the International Society of Ultrasound in Obstetrics and Gynecology.

A case report and analysis of hypertrophic obstructive cardiomyopathy causing an illusion of aortic stenosis

RATIONALE

This study aimed to report a case of hypertrophic obstructive cardiomyopathy causing an illusion of aortic stenosis on imaging.

PATIENT CONCERNS

A 71-year-old woman presented with chest tightness after activity for 1 year and coughing for 2 months. A systolic 3/6 grade murmur was found in the third intercostals of the left border of sternum. Transthoracic echocardiography, transesophageal echocardiography, and magnetic resonance imaging (MRI) were all suggestive of aortic stenosis and left ventricular outflow tract stenosis.

DIAGNOSIS

The patient was diagnosed with "severe aortic stenosis (bicuspid deformity), left ventricular outflow tract stenosis (moderate), and grade II cardiac function." She was advised aortic valve replacement and left ventricular outflow tract dredging. However, no aortic valve lesion was found during the operation, and the diagnosis was changed to "hypertrophic obstructive cardiomyopathy."

INTERVENTIONS AND OUTCOMES

The morrow procedure was performed, and the patient recovered well after the operation. Hypertrophic obstructive cardiomyopathy was found to cause an illusion of aortic stenosis on imaging.

LESSONS

Special attention and rational treatment should be paid to such patients. In addition, further studies are needed to distinguish between the two diseases to reduce misdiagnosis.

Two Cases of Severe Erosive Pustular Dermatosis Mimicking Infection

INTRODUCTION

Erosive pustular dermatosis of the scalp (EPDS) is a noninfectious inflammatory disorder characterized by pustules, erosions, ulcerations, and crusted erythematous plaques that is often associated with mechanical or chemical trauma. While its appearance may mimic infection, its etiology is thought to have an autoimmune component based on responsiveness to immunomodulators.

CASE REPORT

Herein, the authors present 2 cases of EPDS that were initially treated as primary infections. In both cases, the wounds did not respond to antimicrobial treatment and led to severe ulceration, exposing cranial bone. Both wounds improved with topical corticosteroid therapy.

CONCLUSIONS

These cases represent the importance of considering topical steroid treatment and a diagnosis of EPDS after debridement for purulent scalp ulcers.

Misdiagnosis of idiopathic hypoparathyroidism: A case report and literature review

RATIONALE

Idiopathic hypoparathyroidism (IHP) is a rare endocrine condition, which is frequently represented by neuropsychiatric disorders. Hence, the misdiagnosis rate of the disease is rather high, especially for neurologists.

PATIENT CONCERNS

We reported a case of misdiagnosed, atypical IHP. In addition, the literature on IHP and the misdiagnosis published in China in the past 2 decades has been reviewed and summarized.

DIAGNOSES

Blood testing confirmed that parathyroid hormone (PTH) = 0 pg/mL and the final diagnosis was IHP.

INTERVENTIONS AND OUTCOMES

With calcium and vitamin D supplementation, the patient's myasthenia improved significantly, and muscle enzymes returned to normal gradually. One-year follow-up demonstrated that the patient's myasthenia disappeared, and the blood calcium and PTH levels were normal. In addition, the literature on IHP and the misdiagnosis published in China in the past 2 decades has been reviewed and summarized.

LESSONS

The misdiagnosis rate of IHP in China was high in the past 2 decades, which might be attributed to the misdiagnosis as epilepsy or mental diseases. A clinician should be able to understand the disease and emphasize the screening of high-risk population, especially for those patients with hypocalcemia, hyperphosphatemia, and increased blood creatine kinase with unknown causes or nontypical clinical symptoms.

Genotype and clinical course in 2 Chinese Han siblings with Wilson disease presenting with isolated disabling premature osteoarthritis: A case report

RATIONALE

Premature osteoarthritis (POA) is a rare condition in Wilson disease (WD). Particularly, when POA is the only complaint of a WD patient for a long time, there would be misdiagnosis or missed diagnosis and then treatment delay.

PATIENT CONCERNS AND DIAGNOSIS

Two Chinese Han siblings were diagnosed as WD by corneal K-F rings, laboratory test, and mutation analysis. They presented with isolated POA during the first 2 decades or more of their disease course, and were of missed diagnosis during that long time. The older affected sib became disabled due to his severe osteoarthritis when he was as young as 38 years old. Two compound heterozygous pathogenic variants c.2790_2792del and c.2621C>T were revealed in the ATP7B gene through targeted next-generation sequencing (NGS).

LESSONS

Adolescent-onset POA could be the only complaint of WD individual for at least 2 decades. Long delay in the treatment of WD's POA could lead to disability in early adulthood. Detailed physical examination, special biochemical test, and genotyping through targeted NGS should greatly reduce diagnosis delay in atypical WD patients with isolated POA phenotype.

A case study of Ramsay Hunt Syndrome in conjunction with cranial polyneuritis

RATIONALE

Ramsay Hunt syndrome in conjunction with cranial polyneuritis is not extensively documented, and is very easily misdiagnosed.

PATIENT CONCERNS

A case of a 53-year-old male with Ramsay Hunt syndrome in conjunction with cranial polyneuritis is presented with early symptoms of vertigo, cephalalgia, and facial palsy, followed by zoster oticus 10 days later.

DIAGNOSES

Diagnosis was challenging as this condition presents with multiple neuropathies, and attempting to diagnose based on clinical symptoms was often misleading. Polymerase chain reaction can be used to test for presence of the virus in the cerebrospinal fluid, followed by targeted drug therapy.

INTERVENTIONS

Acupuncture, in conjunction with fire cupping, bloodletting around the afflicted region on the face, as well as oral consumption of herbal medicine and vitamins for nerve nourishment was given to treat this disease.

OUTCOMES

Due to misdiagnosis resulting in delayed treatment, peripheral facial paralysis was left as the main sequelae, while other symptoms responded quickly to treatment. After a 6-month follow-up, facial palsy was still present.

LESSONS

Considering that targeted antiviral therapy can be used to increase the effectiveness of treatment, early diagnosis, and timely use of medication is critical.

Missed injuries in pre-hospital trauma patients

BACKGROUND

During primary survey of trauma patients, missed injuries and delayed diagnosis can be a potential source of morbidity and mortality.

OBJECTIVE

To assess type and frequency of missed injuries in prehospital care in trauma patients and to analyze their contributing factors and implications.

METHODS

  It is a descriptive and analytic prospective study. It was performed over six months which had included 200 trauma patients. The initial assessment made by the out-of hospital team of Sousse was compared to the second survey made in the emergency room and intensive care unit after the radiological assessment.

RESULTS

Sixty seven (67) missed injuries were discovered in 51 patients, so 25.5% missed injuries incidence. These injuries were avoidable in 35.82% of cases. Twenty (20) injuries (29.85%) had clinically significant outcomes. Injuries are missed in the abdomen in 62.5% of cases, in the pelvis in 61.11% of cases, in the chest in 41.66% of cases, in the spine in 38.06 % of cases and in 20% of cases in the limbs. Multiple contributing factors were assigned, the most important were: the hemodynamic instability (Systolic blood pressure less than 90 mmHg), the tachycardia and the low RTS. Altered level of consciousness (GCS of twelve or lower), multiple and violence of the trauma were observed but not retained as predictive factors of missing injuries.

CONCLUSION

  Our study showed higher rates of severe missed injuries mainly in abdomen and pelvis. Circulatory instability and low RTS were assigned as significant factors predicting of this obviousness. Various solutions are proposed to prevent missed during the first assessment in prehospital care.

Unrecognized necrosis at same admission cholecystectomy for pancreatitis increases organ failure and infected necrosis

BACKGROUND AND AIMS

Guidelines recommend same admission cholecystectomy (SAC) in the management of mild acute gallstone pancreatitis (AGP) with a recent randomized trial supporting this recommendation. However, the push for early cholecystectomy will lead a subset of patients with evolving, unrecognized necrotizing pancreatitis (NP) to undergo laparoscopic cholecystectomy (LC) with unknown consequences. With concerns about potentially serious outcomes, we studied the outcomes in patients with unrecognized NP who underwent SAC and identified predictors of unrecognized NP at the time of SAC.

METHODS

Retrospective study of patients who appeared to have mild AGP but subsequently discovered to have unrecognized NP after SAC (study group). Outcomes were compared to a similar cohort with necrotizing AGP who did not undergo SAC (control group 1). Predictors for unrecognized NP at the time of SAC were identified through logistic regression using a second control group with truly mild AGP undergoing SAC.

RESULTS

Patients in the study group (N = 46) undergoing SAC demonstrated higher rates of persistent organ failure (p = 0.0003), infected necrosis (p = 0.02), and length of hospital stay (p = 0.049) compared to a similar group (N = 48) with necrotizing AGP who did not undergo SAC. Persistent SIRS (p < 0.0001) and WBC >12 × 10⁹/L (p < 0.0001) on the day of cholecystectomy were associated with evolving/unrecognized NP.

CONCLUSIONS

Unrecognized NP at the time of SAC is associated with increased rates of subsequent persistent organ failure, infected necrosis, and length of hospital stay. Persistent leukocytosis and SIRS at the time of proposed cholecystectomy are predictive of unrecognized NP and should prompt contrast enhanced CT prior to proceeding with LC.

Idiopathic Granulomatous Mastitis: Cytologic and Histologic Study of 65 Egyptian Patients

BACKGROUND

The etiology of idiopathic granulomatous mastitis (IGM) is unknown, and it is commonly misdiagnosed clinically and/or radiologically as breast cancer. The role of fine-needle aspiration cytology (FNAC) in its diagnosis is still a matter of debate. The aim of the current study is to assess the value of FNAC in the diagnosis of IGM, and to search for the presence of bacteria in IGM with cystic vacuoles, which was described recently by a few authors.

MATERIALS AND METHODS

Retrospective study of cytologic smears and histologic tissue sections of 65 Egyptian IGM cases was done along with microbiologic testing. A comparison of the frequency of IGM in Egypt to that of other populations was also made.

RESULTS

IGM has typical FNA features which can easily exclude malignancy. Histologically, cystic vacuoles were encountered in 35 out of 65 cases (53.9%), with only 6 (17.14%) of these cases showing Gram-positive bacilli (GPB). The frequency of IGM in Egypt is comparable to those in other Middle Eastern countries but much higher than in Western countries.

CONCLUSION

IGM is a common breast disease in Egypt. FNAC in IGM has a high diagnostic accuracy. This study supports the few recent studies that have detected GPB in IGM with cystic vacuoles. Thus, bacteriologic examination in such cases may affect the treatment strategy.

Initial misdiagnosis of melanoma located on the foot is associated with poorer prognosis

Acral melanoma has been reported to be associated with poorer outcomes than melanoma occurring on other cutaneous sites. It has been suggested that part of this disparity in outcomes may be related to delay in diagnosis. Therefore, we have analyzed the rate of misdiagnoses in patients with melanoma located on the foot and have characterized the influence on the clinical course and survival of the patients. A prospective, computerized melanoma database at the Skin Cancer Center of the University Hospital Essen, Germany was used to identify patients with histologically confirmed melanoma located on the foot between 2002 and July 2013 for subsequent analysis. A cohort of 151 patients diagnosed with primary melanoma located on the foot was identified. One hundred seven patients qualified for subsequent analysis. Forty-two patients were male (39.3%) and 65 (60.7%) were female; the mean age at first diagnosis was 61.6 years (median 66 years). The youngest patient was 19 years, the oldest 88 years old.Of the 107 patients analyzed, 32 (30%) were initially misdiagnosed. Misdiagnoses included chronic wounds, nevi, hematoma, fungal infections, warts, and paronychia. Misdiagnosis caused a median delay in diagnosis of 9 months. The 5-year disease-free survival rate (47.8% vs 72.7%) and the 5-year overall survival rate (63.5% vs 88.4%) were statistically significant lower in the misdiagnosis cohort.The awareness of potentially overlooked melanoma located on the foot has to increase among physicians.To improve early detection and, thus, the prognosis of patients with melanoma located on the foot, taking a biopsy from any suspicious lesion should be taken into consideration as soon as possible.

Biases in detection of apparent "weekend effect" on outcome with administrative coding data: population based study of stroke

OBJECTIVES

 To determine the accuracy of coding of admissions for stroke on weekdays versus weekends and any impact on apparent outcome.

DESIGN

 Prospective population based stroke incidence study and a scoping review of previous studies of weekend effects in stroke.

SETTING

 Primary and secondary care of all individuals registered with nine general practices in Oxfordshire, United Kingdom (OXVASC, the Oxford Vascular Study).

PARTICIPANTS

 All patients with clinically confirmed acute stroke in OXVASC identified with multiple overlapping methods of ascertainment in 2002-14 versus all acute stroke admissions identified by hospital diagnostic and mortality coding alone during the same period.

MAIN OUTCOMES MEASURES

 Accuracy of administrative coding data for all patients with confirmed stroke admitted to hospital in OXVASC. Difference between rates of "false positive" or "false negative" coding for weekday and weekend admissions. Impact of inaccurate coding on apparent case fatality at 30 days in weekday versus weekend admissions. Weekend effects on outcomes in patients with confirmed stroke admitted to hospital in OXVASC and impacts of other potential biases compared with those in the scoping review.

RESULTS

 Among 92 728 study population, 2373 episodes of acute stroke were ascertained in OXVASC, of which 826 (34.8%) mainly minor events were managed without hospital admission, 60 (2.5%) occurred out of the area or abroad, and 195 (8.2%) occurred in hospital during an admission for a different reason. Of 1292 local hospital admissions for acute stroke, 973 (75.3%) were correctly identified by administrative coding. There was no bias in distribution of weekend versus weekday admission of the 319 strokes missed by coding. Of 1693 admissions for stroke identified by coding, 1055 (62.3%) were confirmed to be acute strokes after case adjudication. Among the 638 false positive coded cases, patients were more likely to be admitted on weekdays than at weekends (536 (41.0%) v 102 (26.5%); P<0.001), partly because of weekday elective admissions after previous stroke being miscoded as new stroke episodes (267 (49.8%) v 26 (25.5%); P<0.001). The 30 day case fatality after these elective admissions was lower than after confirmed acute stroke admissions (11 (3.8%) v 233 (22.1%); P<0.001). Consequently, relative 30 day case fatality for weekend versus weekday admissions differed (P<0.001) between correctly coded acute stroke admissions and false positive coding cases. Results were consistent when only the 1327 emergency cases identified by "admission method" from coding were included, with more false positive cases with low case fatality (35 (14.7%)) being included for weekday versus weekend admissions (190 (19.5%) v 48 (13.7%), P<0.02). Among all acute stroke admissions in OXVASC, there was no imbalance in baseline stroke severity for weekends versus weekdays and no difference in case fatality at 30 days (adjusted odds ratio 0.85, 95% confidence interval 0.63 to 1.15; P=0.30) or any adverse "weekend effect" on modified Rankin score at 30 days (0.78, 0.61 to 0.99; P=0.04) or one year (0.76, 0.59 to 0.98; P=0.03) among incident strokes.

CONCLUSION

 Retrospective studies of UK administrative hospital coding data to determine "weekend effects" on outcome in acute medical conditions, such as stroke, can be undermined by inaccurate coding, which can introduce biases that cannot be reliably dealt with by adjustment for case mix.

Avoiding Errors in the Management of Pediatric Polytrauma Patients

Management of pediatric polytrauma patients is one of the most difficult challenges for orthopaedic surgeons. Multisystem injuries frequently include complex orthopaedic surgical problems that require intervention. The physiology and anatomy of children and adolescent trauma patients differ from the physiology and anatomy of an adult trauma patient, which alters the types of injuries sustained and the ideal methods for management. Errors of pediatric polytrauma care are included in two broad categories: missed injuries and inadequate fracture treatment. Diagnoses may be missed most frequently because of a surgeon's inability to reliably assess patients who have traumatic brain injuries and painful distracting injuries. Cervical spine injuries are particularly difficult to identify in a child with polytrauma and may have devastating consequences. In children who have multiple injuries, the stabilization of long bone fractures with pediatric fixation techniques, such as elastic nails and other implants, allows for easier care and more rapid mobilization compared with cast treatments. Adolescent polytrauma patients who are approaching skeletal maturity, however, are ideally treated as adults to avoid complications, such as loss of fixation, and to speed rehabilitation.

Epileptic seizure in a patient with an implantable cardioverter-defibrillator: Quo vadis right ventricular lead?

The case of a 77-year-old man admitted for suspected epileptic seizure is reported. Patient history showed implantation of a single-chamber implantable cardioverter-defibrillator (ICD) after cardiac arrest in 2007 with replacement in 2012 due to battery depletion; the patient reported no previous syncope, unconsciousness or seizures. Interrogation records of the ICD showed five ventricular tachyarrhythmia episodes that corresponded to the "seizure". Further examination revealed incorrect position of the RV-lead. Diagnosis was a provoked epileptic seizure due to undersensing of ventricular tachycardia because of improper ICD lead implantation in the coronary sinus. Treatment consisted of implantation of a new device with an additional ICD lead into the right ventricle.

[Ocular tuberculosis should not be neglected]

As increasingly frequent immigration in China, the prevalence of drug-resistant tuberculosis (TB) as well as special populations (acquired immune deficiency syndrome, diabetes, etc.) continue to increase, ocular tuberculosis has become an important cause of infectious uveitis. Because the clinical manifestations of this disease manifested in various forms, currently it lacks a unified reliable diagnostic criteria. Misdiagnosis could occur and cause patients' visual loss. The diagnostic criteria for tuberculous uveitis in Chinese patients, the standardized anti-TB therapy and the prevention of tuberculous uveitis in immune dysfunctionalpatients should be made and noted as early as possible by all the ophthalmologists.

MORBIDITY OF SURGERY IN PREVIOUSLY UNDIAGNOSED CIRRHOTIC PATIENTS

BACKGROUND

Undiagnosed cirrhotic patients are frequently encountered during routine and emergency surgery. These patients have a higher incidence of blood loss & wound infection, resulting in prolonged hospital stay. This study was conducted to highlight the possible complications which result in prolonged hospital stay in these patients.

METHODS

A total of 38 patients were incidentally found to have cirrhosis out of a total of 1560 patients who underwent abdominal operation. Diagnosis was confirmed on per-operative liver biopsy and was suspected preoperatively in patient having abnormal liver function test. Per-operative bleeding, postoperative wound infection and hospital stay was compared in cirrhotic and non-cirrhotic patients.

RESULTS

The mean blood loss was 310 ml in cirrhotic patients as compared to 205 ml in non-cirrhotic patients which was statistically significant (p-value 0.008). Post-operative infection rate was 21% in cirrhotic patients compared to non-cirrhotic patients 5%. Significance was tested using Pearson Chi square test (0.042). The Average hospital stay was 10 days in cirrhotic patients and 7.5 days in non-cirrhotic patients respectively which was statistically significant (p-value 0.006).

CONCLUSION

There is statistically significant difference in per-operative bleeding, wound infection and hospital stay in cirrhotic and non-cirrhotic patients.

Can rt-PA be Administered to the Wrong Patient? Two Patients with Somatoform Disorder

Background:

Intravenous rt-PA (IV rt-PA) for acute stroke has raised many concerns, including its inadvertent use in patients presenting with acute stroke-like symptoms as the expression of their somatoform disorder. Diagnosis of the somatoform disorder is often delayed, and thrombolytics in these patients for their stroke-like presentation subjects them to risk for hemorrhage.

Methods:

The presentation, neurological findings, and the therapeutic decision making was audited in 85 patients who received IV rt-PA for a diagnosis of acute stroke. All the surviving patients were re-examined neurologically at least three months after IV rt-PA. Baseline and follow-up brain CT scans were re-reviewed by a neuroradiologist who was blinded to clinical presentation and outcome. Patients whose clinical presentation, brain CT and neurological outcome did not fit into known or expected anatomical and clinical patterns of stroke underwent psychological assessment using the Minnesota Multiphasic Personality Inventory-2.

Results:

In two patients three stroke-like presentations of somatoform disorder inadvertently were treated with IV rt-PA. This was primarily caused by abbreviated neurological examination and narrow differential diagnosis.

Interpretation:

Patients with somatoform disorder may present with symptoms mimicking acute stroke. Under the time constraints of IV rt-PA use, a diagnosis of somatoform disorder can be missed, subjecting such patients to the potential complications of thrombolytics.