Summary and response to the New York Times Well article: Think Like A Doctor: Thinner

We present a succinct overview of the case presented in the New York Times Well article, Think Like A Doctor: Thinner, and discuss how medical calculators and algorithms can assist in coming up with the correct diagnosis as well as a clinical workup and treatment plan.

A 58 year old woman with a several year history of arthritis that seemed to go from joint to joint (migratory polyarthritis). She had been a smoker for several decades (pack year history unknown), although she quit several years ago. She had not felt like herself for quite some time and there was a question of cognitive decline. She had a recent 3 month history of weight loss and persistent cough with upper and lower respiratory symptoms. She had been treated unsuccessfully with several courses of antibiotics for presumed pneumonia (despite normal chest x-ray).

The woman had been following up with her rheumatologist for presumed seronegative arthritis and was on 3 medications for joint pain, including Enbrel, a known immunosuppressant.

Workup for infectious etiologies, like tuberculosis, with CT of the chest revealed multiple enlarged lymph nodes. CT of the abdomen was also performed which revealed enlarged lymph nodes as well. The patient had surgery to obtain lymph tissue from the abdomen with resulting diagnosis of Whipple’s disease.

This case highlights how even over a several year period, patients may be treated for presumed diagnoses with treatments continued despite only minimal improvement in symptomatology. In this case, highlighted by the New York Times, for presumed seronegative rheumatoid arthritis, use of medical algorithms for the diagnosis and treatment of this patients’ presumed rheumatoid arthritis may have alerted other members of the medical team to the possibility of a misdiagnosis.

A few examples of often cited medical algorithms for rheumatoid arthritis.

  • Classification Criteria for Rheumatoid ArthritisClassification Criteria for Rheumatoid Arthritis – 2010 ACR and EULAR criteria
  • Conditions Associated with Positive Assay for Rheumatoid Factor (RF)Conditions Associated with Positive Assay for Rheumatoid Factor (RF)
  • Disease Activity Index for Evaluating Improvement Following Treatment of Rheumatoid ArthritisDisease Activity Index for Evaluating Improvement Following Treatment of Rheumatoid Arthritis

There are over 110 algorithms available via for the diagnosis, treatment/management, and prognosis of rheumatoid arthritis.

The eventual diagnosis, Whipple’s disease is a rare bacterial infection caused by Tropheryma whipplei, which can affect multiple organs and areas of the body. One of the hallmarks is weight loss due to an interference with nutrient absorption.

Highlighted from The Medical Algorithms Company via Lancet (Misbah et al.) some of the other clinical situations where Whipple’s disease should be suspected:

  • Clinical Features of Central Nervous System Involvement in Whipple’s DiseaseClinical Features of Central Nervous System Involvement in Whipple’s Disease – algorithm
    • Unexplained uveitis
    • Neurological disease with myoclonus, dementia and supranuclear ophthalmoplegia
    • Systemic granulomatous disease suggesting sarcoidosis
    • Malabsorption syndrome especially with systemic disease
    • Small bowel or lymph node biopsy showing macrophages with PAS-positive diastase resistant cytoplasmic granules
    • Pulmonary hypertension

This algorithm, using the patient’s history, physical examination, and laboratory findings can assist clinicians in suspecting Whipple’s disease and suggesting additional testing to confirm the diagnosis.

Additionally, there are several other algorithms for Whipple’s disease that can be utilized during the workup, diagnosis, and treatment of this rare condition.

  • Clinical Features of Central Nervous System Involvement in Whipple’s DiseaseClinical Features of Central Nervous System Involvement in Whipple’s Disease
  • Skin manifestations of Whipple’s diseaseSkin manifestations of Whipple’s disease
  • Cardiac involvement in Whipple’s diseaseCardiac involvement in Whipple’s disease
  • Pulmonary hypertension associated with Whipple’s diseasePulmonary hypertension associated with Whipple’s disease

Beyond the eventual diagnosis for this patient, with other etiologies, such as tuberculosis, considered, physicians and other members of the health care team can use medical algorithms to help in their clinical decision making.

There are 70 tuberculosis algorithms available online and via iOS and android app.

When evaluating patients, the ability to easily consult medical algorithms as part of the clinical decision process aids in prompt evaluation and treatment. Whether straightforward conditions or difficult to diagnose cases such as those referenced in the New York Times Think Like a Doctor series, the Medical Algorithms Company provides a valuable resource to clinicians.