The diagnostic eclipse
University of Medicine and Dentistry of New Jersey, Piscataway, United States
In 1919, astronomer Arthur Eddington was studying a photograph of the solar eclipse that occurred just days prior. The sun was completely and perfectly covered by the moon, a breathtaking sight, but Eddington looked past it. He searched for tiny specks of stars just near the eclipsed sun’s edge. These stars, otherwise hidden by the sun’s overwhelming glow, become visible only during eclipses. Their locations appeared to shift, as the stars’ light was bent by the sun’s gravitational field. Eddington’s observation confirmed Albert Einstein’s prediction and proved the general theory of relativity. Medical relevance? In my1 universe of academic rheumatology the subtle pathology (the stars) noticed outside of a known spectacular diagnosis (the eclipsed sun) can change the life of a patient.
"Takayasu’s arteritis!" A call from the medical resident jolted me from a deep sleep at 3am. The young doctor was more scared than fascinated by the rare condition.
“She’s a 35-year-old lady with Takayasu, diagnosed two years ago after presenting with recurrent headaches. She is treated by a rheumatologist with daily prednisone, weekly methotrexate injections, and bimonthly infliximab infusions. Today in the Emergency Department (ED) her headache failed to respond to Reglan, morphine, or Percocet. She is hypertensive at 190/100, but the rest of her vitals, her physical and neurologic exam, labs, and head CT are normal,” he rattled off in one breath. “I am not sure what to do next.”
I appreciated the honesty. Knowing when to call for help is a valuable skill. A call at three o’clock in the morning was terrible for my sleep cycle but perfect for the care of the patient. I recommended lowering the blood pressure, which resolved the headache. For me, the case had just begun.
As a rheumatologist, I take pride in our patients being some of the most mysterious in internal medicine. The immune system is an incredibly elegant and powerful weapon of mass destruction, designed to eliminate anything foreign with remarkable efficacy and precision. The weapon backfiring at its owner and wreaking havoc on several organ systems at the same time produces a kaleidoscope of clinical pathology. Often it’s not a specific clinical finding, but a complex constellation of several, that clinches the diagnosis. Non-rheumatologists often find the clinical and laboratory diagnostics excessively cumbersome. “If it looks rheumatic, just call a rheumatologist,” they sometimes say. Yet over years of clinical experience, I have learned that looks deceive.
The urge to diagnose rapidly from limited data is powerful, becoming stronger with experience. A quick answer impresses colleagues and the patient while validating the impression of a physician’s strong clinical skills. It happens to all doctors, even the best doctors. Experience has taught me to fight the urge to conclude prematurely. Being respectfully skeptical about conclusions and diagnoses made by others is only the next logical step.
I entered the patient’s room trying to mentally blind myself to her diagnosis. For everyone on this case her name was no longer Tanya or Theresa—but “Takayasu.” In a specialty built on recognition of patterns, a bias of premade diagnosis is debilitating. My expectation-affirming self-deception was not going to help this patient. She needed a diagnostic eclipse.
Before me was a thin woman sitting rigidly. Her physical exam was normal. Her affect was flat. Her sister and husband answered most of the questions, and when she spoke, it was in monotone and with painful effort. She avoided eye contact, her shoulders slumped—her voice weak and full of uncertainty. She fell silent after a few questions. The drastic difference in appearance between the patient and her sister brought out a not-so-subtle Cushingoid appearance (moon face and mild buffalo hump) missed by the resident. She displayed none of her family’s energetic and problem-solving attitude.
When asked what was occurring at the time her headaches began, she acknowledged that her father had recently died from a brain tumor. Despite years of intensive immunotherapy, the headaches were getting worse. Treatment with corticosteroid therapy had altered her appearance. Biologic immunosuppressives had weakened her immune system. Before me was a frustrated, withdrawn woman who felt she had lost control over her body and her life.
Later at rounds, I pointed to the least experienced person present, a junior medical student. “How does this patient look?” I asked, expecting him to faint from the stress of having to answer a question that was not multiple choice. “Uhh, her Takayasu appears well-controlled . . .” he answered cautiously. “Forget Takayasu; how does she look?” I asked again. He stared intently. Suddenly in a eureka moment, he produced the response that I had sought from residents four years his senior. “She looks depressed” was the correct answer.
A consulting psychiatrist officially diagnosed depression, possibly precipitated or exacerbated by her therapy. Antidepressants and psychotherapy were advised. On follow-up six months later, the patient reported feeling much better. Her headaches and depression had improved significantly.
Due to the overwhelming shine of Takayasu’s arteritis, her doctors failed to identify her depression for over a year. My team was fortunate to have noticed a woman in deep emotional pain; we were able to not just treat her disease but to also help her feel better. I always try to remember that no amount of focused expertise can make up for clinical fundamentals of general medicine. And for those rare and fascinating diagnoses, I look for stars around the eclipse.
- Dr. Schlesinger is the primary author of this essay and the physician whose experiences have formed the basis for the narrative. Identifying details have been changed to protect patient confidentiality.
NAOMI SCHLESINGER, MD, is a professor of medicine and the chief of the division of Rheumatology at the University of Medicine and Dentistry/Robert Wood Johnson Medical School. She is currently the president of the New Jersey Rheumatology Association and the co-chair of both the crystal abstract committee and the crystal study group at the American College of Rheumatology. She has been a prolific writer on diverse topics, writing and publishing manuscripts, chapters, and abstracts mainly related to her clinical and research activity, concentrating in the last years on gout pathogenesis and its treatment.
GREGORY MANIATIS, MD, is a PGY4 Cardiology fellow in the department of Internal Medicine at the University of Medicine and Dentistry/Robert Wood Johnson Medical School
RANITA SHARMA, MD, is an associate professor of medicine at the University of Medicine and Dentistry/Robert Wood Johnson Medical School.
BORIS D. VEYSMAN, MD, is an emergency medicine specialist at the Robert Wood Johnson Hospital in New Brunswick, New Jersey. His narratives have been published in Journal of the American Medical Association, the British Medical Journal, the Annals of Internal Medicine, the Annals of Emergency Medicine, the Washington Post, Health Affairs, and the New England Journal of Medicine website, as well as aired on National Public Radio. Dr. Veysman’s desire to empower physicians to achieve top clinical performance inspires his work. He finds understanding the patient through the eyes of a specialty consultant essential to effective practice of emergency medicine. Dr. Schlesinger's generous insights in this collaboration were an invaluable clinical lesson.