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PubMed2001

Pitfalls in the emergency department diagnosis of acute myocardial infarction.

The accurate assessment and triage of patients with potential ACS is a complex decision-making process based on information that is not entirely reliable. The knowledgeable EP recognizes that assessment of patients with chest pain requires an understanding of the various clinical presentations of ACS and high-risk patient types, as well as careful use of the available modalities to diagnose these syndromes efficiently while incurring minimal risk to the patients safety. The busy EP is faced with sick patients with chest pain daily, so that it behoove anyone in emergency medicine to familiarize themselves with these diagnostic pitfalls.

Adult↗

PubMed1990

Ectopic pregnancy: ten common pitfalls in diagnosis.

Ectopic pregnancy (EP) is a common, life-threatening complication of pregnancy. Modern technology (ultrasonography and improved pregnancy tests) should facilitate the diagnosis of EP. However, in a retrospective review of 65 cases of confirmed EP managed over 18 months at an urban teaching hospital, only 37 of 65 patients (57%, Cl95 = 44%, 69%) received prompt diagnosis and treatment; delays occurred in 28 patients (43%). In 10 of the 27 delayed cases, the diagnosis of EP was not even considered at the time of the first visit. In patients with a delayed diagnosis, morbidity (transfusions, cardiovascular instability, progression of illness) did occur. Diagnostic pitfalls that resulted in delayed care were reviewed, delays most commonly occurred in patients with a benign examination or "atypical" pain. Risk factors for EP were missed (7 patients, 25%), subtle clues to blood loss were often ignored (10 patients, 36%), and passage of tissue was thought to exclude EP (2 patients). Ultrasound was only helpful for half of the diagnoses and was misinterpreted in 27%. A dry or serous culdocentesis occurred frequently. In five patients, a falling or low quantitative human chorionic gonadotropin level was believed to indicate a completed abortion. The authors conclude that almost half of EPs are still missed on the first physician visit; errors and pitfalls in diagnosis are still common in the 1980s.

Adolescent↗

PubMed2000

Subacute Budd-Chiari syndrome associated with polycythemia vera and factor V Leiden mutation.

We describe a 48-year-old caucasian woman with a subacute Budd-Chiari syndrome attributed to the presence of polycythaemia vera, heterozygosity for the factor V Leiden mutation and the use of an oral contraceptive pill. Two diagnostic pitfalls were encountered. First, on CT scanning of the abdomen the still normally vascularized central part of the liver was initially judged as a hypervascular tumour. Second, there was difficulty to recognize the thrombocytosis/leukocytosis in relation with portal hypertension and hypersplenism. Our case illustrates the obstacles which can be faced during the diagnostical process in a subacute form of Budd-Chiari syndrome. Furthermore, our case illustrates the need for routinely screening of the factor V Leiden mutation in patients with Budd-Chiari syndrome.

Acute Disease↗

PubMed1990

Immunohistochemistry of solid tumors. Brief review of selected problems.

The immunohistochemical approach to tumor typing has dramatically improved our possibilities in the objective diagnosis of neoplasms. Use of optimal material and careful techniques will help to maintain good sensitivity, specificity, and reproducibility of immunohistochemistry. However, the complexity of antigen patterns in tumors, and lack of comprehensive knowledge about them requires caution in the interpretation of results, and may prohibit the simple use of diagnostic algorithms. Especially it is not certain whether the results obtained from typical representatives of various tumor entities will pertain to borderline cases and to undifferentiated variants of the same entities. Use of panels of antibodies rather than the use of single "diagnostic" tests will help to avoid these diagnostic pitfalls. However, all tumor types do not have immunohistochemically distinctive features. This emphasizes the need to use other techniques in such cases, and also suggests that some entities, such as malignant fibrous histiocytoma, are from the point of view of immunohistochemistry diagnoses only made by exclusion rather than being specifically diagnosable entities. All diagnostic immunohistochemistry has to be interpreted in the context of standard histological examination.

Antigens, Neoplasm↗

PubMedDate not supplied

US of the major salivary glands: anatomy and spatial relationships, pathologic conditions, and pitfalls.

Ultrasonography (US) is useful for differential diagnosis of diseases of the salivary glands. In acute inflammation, salivary glands are enlarged and hypoechoic with increased blood flow; they may contain multiple small, oval, hypoechoic areas. In chronic inflammation, salivary glands are normal sized or smaller, hypoechoic, and inhomogeneous. Sialolithiasis appears as markedly hyperechoic lines or points with distal acoustic shadowing. Sialosis appears as enlarged hyperechoic glands without focal lesions or increased blood flow. The US features of advanced Sjögren syndrome include inhomogeneous salivary glands with scattered small, oval, hypoechoic or anechoic areas, usually well defined, and increased parenchymal blood flow. Pleomorphic adenomas are usually hypoechoic, well-defined, lobulated lesions with posterior acoustic enhancement that may contain calcifications; Warthin tumors are usually oval, hypoechoic, well-defined lesions that often contain anechoic areas and are often hypervascularized. Malignant neoplasms of the salivary glands may have irregular shapes, irregular borders, blurred margins, and a hypoechoic inhomogeneous structure or may have a benign appearance. Salivary gland cysts have well-defined margins, anechoic contents, posterior acoustic enhancement, and no internal blood flow. However, US appearances of some diseases may overlap, thus producing diagnostic pitfalls.

Diagnosis, Differential↗

PubMed2004

(201)Tl-SPECT in low-grade gliomas: diagnostic accuracy in differential diagnosis between tumour recurrence and radionecrosis.

PURPOSE: The aim of this work was to describe the usefulness of a simple (201)Tl single-photon emission computed tomography (SPECT) technique in the differential diagnosis between tumour recurrence and radionecrosis during the follow-up of patients treated for low-grade gliomas. METHODS: The study population comprised 84 patients treated for low-grade gliomas who showed suspicion of tumour recurrence during their follow-up. All patients were examined by neuro-anatomical imaging procedures (CT, MRI) and (201)Tl-SPECT. (201)Tl-SPECT images were assessed by visual analysis based only on the information on the prescription form and by estimation of the uptake index (ratio of mean counts in the lesion to those in the contralateral mirror area). Examiners were blinded to the results of other tests. RESULTS: Under these conditions, the neuro-anatomical procedures yielded 26.2% inconclusive reports, with a global diagnostic accuracy of 0.61, a sensitivity of 0.63 and a specificity of 0.59. The global diagnostic accuracy for (201)Tl-SPECT was 0.83, with a sensitivity of 0.88 and a specificity of 0.76. Diagnostic pitfalls were observed in regions with physiological (201)Tl uptake, i.e. the posterior cranial fossa, diencephalon, lateral ventricles and cavernous and longitudinal venous sinuses. An uptake index cut-off value of 1.25 showed a sensitivity of 0.90 and specificity of 0.80 for detection of tumour activity. CONCLUSION: (201)Tl-SPECT has adequate diagnostic accuracy to be part of routine algorithms in the follow-up of patients with low-grade glioma suspected of tumour recurrence, as an alternative to neuro-anatomical procedures and not solely as a complementary test.

Adult↗

PubMed2002

Three-dimensional ultrasonographic presentation of micrognathia.

OBJECTIVE: To present the variable appearance of micrognathia in fetuses by three-dimensional ultrasonography and to describe practical methods for analysis of these volume data. METHODS: Three-dimensional multiplanar imaging and surface-rendering techniques were used to show various syndromes and diagnostic approaches for the evaluation of fetal micrognathia. RESULTS: Nine cases of fetal micrognathia are presented. Orthogonal multiplanar views were used to obtain a midsagittal facial profile. Examples of micrognathia include 3 cases of Pierre Robin sequence, cerebrocostomandibular syndrome, Cornelia de Lange syndrome, and hypochondrogenesis. Diagnostic pitfalls for micrognathia are also shown. CONCLUSIONS: Three-dimensional multiplanar imaging increases the likelihood that a true midline sagittal view of the facial profile is being analyzed. Surface rendering provides another way to qualitatively evaluate the fetal chin from different viewing perspectives. Three-dimensional ultrasonographic methods are useful adjuncts to the preliminary diagnostic impression from two-dimensional ultrasonography.

Abnormalities, Multiple↗

PubMedDate not supplied

Pitfalls in CT evaluation of chest wall invasion by lung cancer.

Computed tomography in a patient with a peripheral lung cancer in the right upper lobe revealed obliteration of the extrapleural fat and direct connection of the tumor with an intercostal soft tissue mass of similar density. The findings were suggestive of chest wall invasion by the cancer which was, however, proven to be false after en bloc resection of the tumor and the contiguous chest wall. Such a diagnostic pitfall could be avoided if special attention were paid to the asymmetry of the CT image at the level of upper thoracic outlet due to improper positioning of the patient.

Adenocarcinoma↗

PubMedDate not supplied

US of neurovascular occlusive disease: interpretive pearls and pitfalls.

Ultrasonography (US) of the head and neck is a convenient but operator-dependent screening tool for detection and diagnosis of neurovascular occlusive disease. In US examination of the extracranial carotid arteries, stenosis is most commonly graded according to the peak systolic Doppler velocity in the region of maximal luminal narrowing rather than according to the percentage of atheromatous plaque occupying the lumen. However, the peak systolic velocity is not always reliable in estimation of the degree of stenosis. General diagnostic pitfalls include technical difficulties with scanning, failure to review the spectral waveform patterns, the presence of additional stenotic lesions, and anatomic variants. Specific examples of pitfalls include tandem lesions, differentiation of pseudo-occlusion from true total occlusion, pseudonormalization of velocities in cases of very severe stenosis, lesions of the carotid artery origin or aortic valve, progression of subclavian steal, underestimation of severe stenosis due to heavily calcified plaque, a persistent trigeminal artery, and contralateral carotid artery stenosis. Although conventional angiography remains the standard of reference for assessment of carotid artery disease, recognition of these common sources of error in US can improve the accuracy of this noninvasive test in diagnosis of carotid artery occlusion.

Arterial Occlusive Diseases↗

PubMed2005

Increased accumulations of N-isopropyl-p-[123I]-iodoamphetamine related to tumefactive multiple sclerosis.

We present a 21-year-old woman with tumefactive multiple sclerosis (MS) that exhibited a rapidly progressive course. There were multiple tumor-mimicking contrast-enhance lesions with surrounding edema and mass effect on magnetic resonance imaging. Both early and delayed brain single photon emission computed tomography (SPECT) with N-isopropyl-p-[123I]-iodoamphetamine demonstrated increased accumulations of the tracer and a high retention on the lesions. The SPECT findings represent a diagnostic pitfall for distinguishing MS from malignant brain tumors in patients with intracranial tumor-like lesions.

Adult↗

PubMed1980

The role of computed tomography in assessment of tumoral pathology of the adrenal glands.

The findings at computed tomography (CT) of the adrenal glands in 58 patients are presented. Most patients (50) were referred for suspected adrenal dysfunction. In three, adrenal masses were suspected from other radiological studies. Three patients had palpable abdominal masses, and incidental adrenal metastases were found in two. Pathological findings included pheochromocytomas (nine patients), adrenocortical adenomas (six), adrenocortical carcinomas (three), metastases (two), and one example each of myelolipoma, hemorrhagic renal cyst, and probable granuloma. Of 24 adrenal masses, 23 were clearly apparent in the scans and one was suspected. The smallest tumor diagnosed was 0.5 cm in diameter. There was on false positive diagnosis of a small tumor and no known false negatives. Because of their consistent location and unusual shape and because they are usually surrounded by retroperitoneal fat, the adrenal glands are ideal organs for study by CT, a highly accurate method for detecting and excluding mass lesions that may render arteriography and venography unnecessary. Surgery was performed in five patients with tumors following localization by CT only. Limitations and potential diagnostic pitfalls in interpretation are discussed.

Adolescent↗

PubMed1976

Radiologic classification of posterior dislocations of the hip: refinements and pitfalls.

Seventeen traumatic hip dislocations seen during a 15-month period were evaluated. In 10 of the 14 cases of posterior hip dislocation, the final Thompson-Epstein classification differed from the initial radiographic classification. Dislocations of the hip often result in radiographically obscure femoral head and acetabular damage. High quality radiographs with oblique and coned-down views are of substantial aid in evaluating the dislocated hip. After closed reduction of a dislocated hip, further views and tomography are helpful but diagnostic pitfalls exist. A persistently widened hip joint, even with negative plain films and tomography, indicates possible intra-osteochondral debris or incompletely reduced femoral head fragments.

Adolescent↗

PubMed1983

[Pitfalls in the diagnosis of spinal injuries].

Injury to the spinal cord remains one of the great disasters which can disrupt any person's life. Although tremendous progress has been made concerning treatment and rehabilitation, our inability to change the irreversible nature of these injuries still underlines the vital importance of their prevention. Saving a patient from potential neurological damage depends upon the early recognition of unstable spinal injuries. Unfortunately, prompt diagnosis is not always the rule. We have identified the following seven diagnostic pitfalls in this regard, and again emphasize a few basic rules in dealing with them: (i) the 'sprained neck'; (ii) the normal radiograph; (iii) head injuries; (iv) multiple injuries; (v) the low cervical region; (vi) high dorsal lesions; and (vii) double spinal injuries.

Cervical Vertebrae↗

PubMed1992

Pitfalls in the histopathologic diagnosis of pyogenic granuloma.

The term pyogenic granuloma (PG) is a misnomer. The histopathologic appearance is fairly characteristic, the lesion being in fact a lobular capillary hemangioma. The recognition of PG as a clinically polypoid or exophytic, circumscribed lesion is of importance to both the clinician and the pathologist, as this feature distinguishes PG from most malignant vascular tumors. Although PG may be multiple, especially on the skin, and necrosis is not uncommon, invasion of adjacent structures is not seen. Diagnostic pitfalls occur histologically when the characteristic lobular configuration of PG is not recognized because of a solid growth pattern of endothelial proliferation, the presence of brisk mitosis, intervascular stromal fibrosis or spindle cell proliferation, and occasionally an epithelioid appearance of endothelial cells. The different vascular neoplasms that may be confused with PG are discussed, and the clinical and histopathologic features of PG are emphasized.

Angiolymphoid Hyperplasia with Eosinophilia↗

PubMed1993

Dental follicular tissue: misinterpretation as odontogenic tumors.

The dental follicle is radiographically and histologically observed in association with unerupted or impacted teeth. However, this normal tissue structure is often confused with odontogenic tumors by pathologists with limited experience in evaluating jaw lesions. This study was designed to evaluate the incidence and possible reasons for incorrect interpretation of dental follicles. From 1970 to 1988, 847 dental follicles and/or dental papillas from 663 patients were submitted to the Armed Forces Institute of Pathology (AFIP) by medical pathologists seeking diagnostic consultation. Nearly 84% of patients were in the second and third decades of life. The male to female ratio was 1.4:1.0. Over 70% of specimens were obtained from around impacted third molar teeth. Fifty-three percent of specimens were correctly interpreted by the contributing pathologists. Only a descriptive interpretation was given for 17%, no diagnosis was made in 10%, and 20% were incorrectly diagnosed. In descending order, the most frequent incorrect diagnoses were odontogenic cyst, odontogenic myxoma, odontogenic fibroma, ameloblastic fibroma, odontoma, and ameloblastoma. Dental papillas were most frequently misdiagnosed as odontogenic myxomas. The histologic features and diagnostic pitfalls are discussed, as well as the need to consider the clinical, radiographic, and microscopic features in arriving at a final diagnosis.

Adolescent↗

PubMedDate not supplied

Evaluating the diagnostic significance of nuclear grooves in thyroid fine needle aspirates with a semiquantitative approach.

OBJECTIVE: To clarify the diagnostic significance of nuclear grooves in thyroid fine needle aspirates, to search for other associated nuclear features and to identify possible diagnostic pitfalls. STUDY DESIGN: In total, 67 fine needle aspiration cases were retrospectively reviewed for selected nuclear features, including grooves, intranuclear cytoplasmic invaginations, enlargement, pleomorphism and status of nucleoli. A semiquantitative method was used to estimate the percentage of nuclear grooves in 5 high-power fields with the most frequent nuclear grooves. RESULTS: Unequivocal intranuclear cytoplasmic invaginations were a specific diagnostic feature of papillary carcinoma. In the absence of intranuclear cytoplasmic invaginations, the presence of > or = 20% nuclear grooves was virtually diagnostic of thyroid neoplasms, predominantly papillary carcinoma. Less than 10% of nuclear grooves virtually eliminated the possibility of papillary carcinoma. However, 10-19% of nuclear grooves may be seen in papillary carcinoma and benign lesions; therefore, such cases fell into the diagnostic category of "atypical cytology" or "indeterminate" cytology. Nuclear enlargement with elongation was a readily identifiable feature usually associated with nuclear grooves. Significant pleomorphism was more commonly seen in papillary carcinoma than in benign lesions. CONCLUSION: A semiquantitative method is helpful when nuclear grooves are encountered in thyroid cytology in the absence of other diagnostic features. It can significantly improve the diagnostic specificity of nuclear grooves for papillary carcinoma.

Biopsy, Needle↗

PubMed1989

Monoclonal antibody B72.3. An adjunct for evaluation of suspicious aspiration biopsy cytology from the breast.

Monoclonal antibody B72.3 (MoAb B72.3) is a potentially valuable diagnostic adjunct when applied to aspiration biopsy cytology (ABC). In this prospective study, its reactivity was tested on the ABC from 25 breast lesions interpreted as suspicious. The stain was applied directly to the Papanicolaou-stained specimen by the avidin-biotin peroxidase methodology at a concentration of 40 micrograms/ml. In 11 aspirates from invasive carcinomas, the reactivity to MoAb B72.3 was strongly positive in nine cases and weakly positive in two. Ten of these tumors were homogeneous or heterogeneous infiltrating lobular neoplasms, tumors causing special diagnostic pitfalls by ABC. The cells from seven of the nine benign lesions were nonreactive, and in two cases from fibrocystic change, weakly reactive. The ABC from five patients with noninvasive carcinomas or atypical lobular hyperplasia showed a variety of responses. The findings indicate that in select circumstances, MoAb B72.3 used in conjunction with clinical and cytologic findings may be a useful diagnostic adjunct.

Antibodies, Monoclonal↗

PubMed2005

Distribution of cytokeratins and vimentin in adult renal neoplasms and normal renal tissue: potential utility of a cytokeratin antibody panel in the differential diagnosis of renal tumors.

Adult renal epithelial neoplasms (RENs) comprise several distinct clinicopathologic entities with potential prognostic and therapeutic differences. Individual cases can show overlapping morphologic features, necessitating the use of ancillary methods. The purpose of this study was to determine the diagnostic utility of cytokeratin (CK) subtype expression pattern in a wide range of adult RENs. RENs (including clear cell [conventional] renal cell carcinoma (RCC), papillary RCC, chromophobe RCC, renal oncocytoma, collecting duct carcinoma (CDC), renal medullary carcinoma (RMC), urothelial carcinoma, metanephric adenoma (MA), tubulocystic carcinoma (TC) (also known as low-grade collecting duct carcinoma), and mucinous tubular and spindle cell carcinoma) were immunostained for CK subtypes (CK5/CK6, 7, 8, 13, 14, 17, 18, 19, 20), high molecular weight CKs 1, 5, 10, 14 (HMWCK), and vimentin (Vim). The expression pattern of normal kidney was also examined and correlated with RENs. Although there is some overlap, subtypes of RENs show distinctive CK expression profiles that may be useful in several differential diagnostic settings. Clear cell RCCs typically showed a restricted expression pattern of CK8, CK18 and Vim. Papillary RCCs typically expressed CK7, CK8, CK18, CK19, and Vim and could be distinguished from MA (CK7-). Chromophobe RCCs were typically CK7+, CK8+, CK18+, and Vim-, and could be distinguished from oncocytomas (typically CK7-). In oncocytomas, nonspecific staining of unblocked endogenous biotin is a potentially significant diagnostic pitfall. CDC, RMC, and TC demonstrated similar CK expression profiles (with the exception of HMWCK expression limited to CDC), supporting a close relationship between these entities. A panel of CK5/CK6, CK17, and Vim may be helpful in distinguishing CDC (typically CK5/CK6-, CK17-, Vim+) and urothelial carcinoma (typically CK5/CK6+, CK17+, Vim-). In conclusion, CK expression patterns may be helpful in several differential diagnostic situations when dealing with adult RENs.

Adult↗