| HOME | HELP | FEEDBACK | SUBSCRIPTIONS | ARCHIVE | SEARCH | TABLE OF CONTENTS |
Guest Access | Sign In via User Name/Password
|
|
|
|||||||
Guest Access | Sign In via User Name/Password |
|||||||||
Dr. Kvale is Professor of Medicine, Case Western Reserve University School of Medicine, and Senior Staff Physician, Division of Pulmonary and Critical Care Medicine, Henry Ford Health System.
Correspondence to: Paul A. Kvale, MD, FCCP, Division of Pulmonary, Critical Care, Allergy and Immunology, and Sleep Disorders Medicine, Henry Ford Health System, 2799 West Grand Blvd, Detroit, MI 48202; e-mail: pkvale1{at}hfhs.org
Some diseases are inherently more difficult to diagnose with certainty than others. Most diseases are easier to diagnose when the clinical presentation fits the paradigm that we learn as a function of our training and experience. The opposite is also true—if the presentation is atypical, the diagnosis becomes much more difficult. One such example is a pulmonary embolus that complicates severe chronic obstructive lung disease, particularly if the patient is being supported by mechanical ventilation.1 Pulmonary physicians are likely to be a little surprised at the data presented by Judson and his colleagues in the current issue of CHEST (see page 406), in which they detail the difficulty encountered by physicians in making a definitive diagnosis of sarcoidosis. This was especially true when patients with sarcoidosis had pulmonary symptoms as the presenting problem; however, when skin manifestations were the first thing noticed by the patient and the physician, the tissue diagnosis of sarcoidosis was made significantly quicker. Does this mean that it is easier to recognize and adequately categorize the skin lesions as typical of sarcoidosis? Not necessarily, but the authors point out that skin biopsies are likely to be done if the skin lesions do not respond to the initial treatment. That makes sense to me; I struggle with most dermatologic diagnoses, and I am quick to call a consultant to help me for all but the simplest of dermatologic problems. And dermatologists proceed to sample such lesions, often at the time of the first encounter.
I would like to think that most pulmonary physicians would be more likely to diagnose sarcoidosis correctly and timely when the patients come to us with a pulmonary problem. A severe bias is built into this thinking, however. By the time such a patient gets to the office of a pulmonary physician, another physician or the patient has already determined that a pulmonary problem likely exists. Most of these patients come with a chest radiograph in hand, showing abnormal findings. So it would seem that pulmonary physicians would automatically consider sarcoidosis in the differential diagnosis. Pulmonary physicians are more likely to know the typical and atypical symptoms for sarcoidosis, the accompanying abnormal physical findings, and especially what the spectrum of sarcoidosis chest radiographs look like. For a pulmonary physician with such a patient, therefore, sarcoidosis likely would be high in the list of things to consider and a biopsy (if indicated) would quickly follow.
That is not the case for patients, most of whom have never heard of sarcoidosis. And it appears not to be true for the doctor of first record—the primary care physician, whatever his or her general or specialty training might be, unless the presenting problem is a skin lesion. Even then, the primary care physician may not be thinking about sarcoidosis, but the biopsy is done quickly and the diagnosis is therefore made more quickly.
What makes the diagnosis of pulmonary sarcoidosis more difficult for the primary care physician? The pulmonary symptoms that accompany sarcoidosis, if any symptoms are present, typically include cough and dyspnea. Wheezing may also be present. These symptoms are nonspecific, and they may accompany many respiratory disorders. Since bronchitis and asthma are much more common respiratory diseases, treatment with bronchodilators, aerosolized steroids, and antibiotics is a reasonable initial approach. Indeed, patients may report improvement in their symptoms with such treatment. As bronchitis and asthma can be managed very well, much of the time, without ever obtaining a chest radiograph, a delay in the diagnosis of sarcoidosis when pulmonary symptoms are present begins to be more understandable.
Less well appreciated is the fact that airflow obstruction is quite common with sarcoidosis. This probably relates to the frequency of mucosal airway involvement by the inflammatory granulomatous process, and also to stenoses of multiple airways that develop during the natural history of sarcoidosis.2 3 4 Thus, wheezing and cough are common complaints for patients with sarcoidosis too. Spirometry often will confirm airflow obstruction, but reversibility after bronchodilators is not typically seen.3 Nevertheless, the finding of airflow obstruction may have the effect of reinforcing the diagnosis of asthma, with or without bronchitis, leading to additional potential delays in making the correct diagnosis of sarcoidosis.
Many of the radiographs that were eventually ordered in the study by Judson et al showed advanced changes (Scadding stage 3 or 4), and the symmetrical hilar lymphadenopathy seen with Scadding stage 1 or 2 radiographic findings that might have stimulated consideration of sarcoidosis would not be seen. Without typical symmetrical hilar lymphadenopathy, thoughts about sarcoidosis to explain Scadding stage 3 and 4 changes may not even come to the mind of physicians who do not see many patients with sarcoidosis. For patients to present with this type of advanced radiographic abnormality also suggests that the onset of symptoms may have been very gradual and less likely to stimulate the patient to complain very much to his doctor. Under these circumstances, a delay in ordering chest radiographs, or in referring patients to a pulmonary consultant, again becomes easier to understand.
One additional point might be in order as we think about the report by Judson and colleagues. Their reported methodology used the date of tissue biopsy as the time for the definitive diagnosis of sarcoidosis. Not all patients with sarcoidosis require tissue biopsy for a physician to feel confident of the diagnosis. This is especially true for asymptomatic patients with Scadding stage 1 chest radiographic abnormalities (bilateral hilar adenopathy with normal lung parenchyma). When symptoms such as erythema nodosum are accompanied by a Scadding stage 1 chest radiographic abnormality, even greater confidence is warranted in the diagnosis without the need to proceed to biopsy. Winterbauer et al5 presented a convincing argument that these two types of patients did not need a biopsy for the physician to be confident that the patient likely had sarcoidosis and not a lymphoma. Since patients in the study by Judson and colleagues were not counted as "diagnosed" until they had biopsy confirmation of their diagnoses, it may be that the primary care physicians and the pulmonary physicians whom they consult generally perform better than the data in this report would suggest.
References
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| HOME | HELP | FEEDBACK | SUBSCRIPTIONS | ARCHIVE | SEARCH | TABLE OF CONTENTS |
