Correspondence

Clinical Problem-Solving: Remembering the ABC's

N Engl J Med 1994; 331:551August 25, 1994

Article

To the Editor:

In the Clinical Problem-Solving case presented by Duffy (April 7 issue),1 three ophthalmologists misdiagnosed vitamin A deficiency as simple conjunctivitis in a 40-year-old woman with mild Down's syndrome who had severe eye pain. The discussant (a nephrologist) and the author attributed their error to a number of factors: a tendency of physicians to overlook nutritional conditions; lack of familiarity with the patient's complex medical history, which made her a compromised host; and the rarity of vitamin A deficiency in the United States. I propose an additional explanation -- that medical decision making was influenced by a tendency to take less seriously the symptoms reported by a mentally retarded person.

How were this patient's corneas examined? Was a slit lamp used? Was even bedside fluorescein staining performed? These basic procedures could have identified corneal ulcers long before the four-week period during which the unfortunate woman's eyes had “nearly swollen shut” and her vision “markedly decreased.” Perhaps the ophthalmologists underestimated the history of eye pain. How much time did they spend talking to the patient? Did they consider her an unreliable historian?

Steven Leiner, F.N.P., P.A.
Mission Neighborhood Health Center, San Francisco, CA 94110

1 References

1
Duffy TF. Remembering the ABC's. N Engl J Med 1994;330:994-996
Full Text | Web of Science | Medline

To the Editor:

We would like to call attention to another disorder that can cause bilateral eye pain in a patient with Down's syndrome. It is well known that autoimmune thyroiditis is much more common in patients with Down's syndrome, especially females, than in the general population1. We therefore think that hypothyroidism should have been considered as a possible diagnosis, with thyroid-associated ophthalmopathy as the cause of redness, bilateral eye pain, swelling, corneal ulcers, and blindness2. We suggest that thyroid-function tests, antiperoxidase antibody testing, and a computed tomographic scan should have been requested.

Flavio Zelmanovitz, M.D.
Jorge L. Gross, M.D.
Hospital de Clinicas de Porto Alegre, Porto Alegre CEP 90035, Brazil

2 References

1
Fialkow PJ, Thuline HC, Hecht F, Bryant J. Familial predisposition to thyroid disease in Down's syndrome: controlled immunoclinical studies. Am J Hum Genet 1971;23:67-86
Web of Science | Medline

2
Wall JR. Pathogenesis and management of thyroid associated ophthalmopathy: an update. Thyroid Today 1991;14:1-9

Author/Editor Response

Dr. Duffy replies:

To the Editor: The patient's mental retardation undoubtedly delayed the recognition of vitamin deficiency as the cause of her loss of vision. Not only was the patient unable to provide early clues to vitamin A deficiency (progressive night blindness), but she also resisted close examination of her eyes; a slit-lamp examination would have required anesthetizing her. Her symptoms were taken seriously, but unfortunately the link to vitamin A deficiency was not made.

The same oversight did not pertain to thyroid deficiency as a possible cause of her condition, as correctly suggested by Drs. Zelmanovitz and Gross. Thyroid-function tests have become part of the standard checklist of laboratory studies. The classic physical clues to the diagnosis have been losing sway now that thyrotropin values are as readily available as serum electrolyte values.

Thomas P. Duffy, M.D.
Yale University School of Medicine, New Haven, CT 06510

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