Correspondence

Impatient Inpatient Care

N Engl J Med 2000; 342:1678-1679June 1, 2000

Article

To the Editor:

It is not uncommon for a patient's occupational history to provide an essential clue leading to the correct diagnosis. Insights into the causes of a patient's persistent fever might be informed by knowledge of the patient's lifestyle or occupation: for example, the source could be endocarditis in an intravenous drug user or tularemia in a rabbit hunter. However, when such insights derive from shaky clinical science, the clinician abandons both professional objectivity and patient advocacy.

A case in point is the recent Clinical Problem-Solving article by Gulati et al. (Jan. 6 issue),1 in which the discussant starts off by noting: “In a retired painter, one thinks of lead intoxication or chronic alcoholism.” Lead exposure is plausible, but the statistical association between chronic alcoholism and retired painters is tenuous,2 and the published data are of questionable relevance to the case at hand.3 The discussant also notes, “The possibility of HIV [human immunodeficiency virus] disease should perhaps have been mentioned earlier, since a merchant seaman might have acquired the infection.” So might also a fisherman4 or a landlubber.5 The sparse published data on these associations are weak and contradictory. This insidious form of clinical “profiling” is worthy of comment.

Thomas Michel, M.D., Ph.D.
Veterans Affairs Boston Healthcare System, Boston, MA 02132

5 References

1. 1

   Gulati M, Saint S, Tierney LM Jr. Impatient inpatient care. N Engl J Med 2000;342:37-40
   Full Text | Web of Science | Medline

2. 2

   Olkinuora M. Alcoholism and occupation. Scand J Work Environ Health 1984;10:511-515
   CrossRef | Web of Science | Medline

3. 3

   Lundberg I, Gustavsson A, Hogberg M, Nise G. Diagnoses of alcohol abuse and other neuropsychiatric disorders among house painters compared with house carpenters. Br J Ind Med 1992;49:409-415
   Medline

4. 4

   Towianska A, Dabrowski J, Rozlucka E. HIV antibodies in seafarers, fishermen and in other population groups in the Gdansk Region (1993-1996). Bull Inst Marit Trop Med Gdynia 1996;47:67-72
   Medline

5. 5

   Kelley PW, Miller RN, Pomerantz R, Wann F, Brundage JF, Burke DS. Human immunodeficiency virus seropositivity among members of the active duty US Army 1985-89. Am J Public Health 1990;80:405-410
   CrossRef | Web of Science | Medline

To the Editor:

Gulati et al. may have overlooked some historical information that could have led to the correct diagnosis sooner. It is presented in the very first paragraph of their article, where it is disclosed that the patient was a painter. The discussant properly notes the risk of lead toxicity, presumably from scraping off old paint, and alcoholism, possibly from the repetitive nature of the work and the relative ease of access to alcoholic beverages on the job. However, an additional disorder may be even more commonly encountered in persons of this occupation. It is histoplasmosis, the final diagnosis in this case. Histoplasmosis could have been contracted by the painter because of extensive exposure to bird (probably pigeon) droppings. Indeed, the initial symptoms described in the succeeding paragraphs are entirely consistent with a diagnosis of acute histoplasmosis. Combined with the knowledge that the patient worked in an area in which this fungal disease is endemic, the clinicians might very well have arrived at the correct answer early on.

Camilla A. Payne, R.N.
531 Keith Ave., Anniston, AL 36207

Author/Editor Response

Dr. Tierney replies:

To the Editor: Michel's comments raise issues central to clinical problem-solving in real time. As the discussant in this case, I relied on three decades of personal experience, plausible anecdotes learned over the years from physicians I respect, and my own awareness of the medical literature. Indeed, the strongest possible advocacy for patients comes from developing a broad differential diagnosis, derived from all reasonable sources. It is seldom possible to apply an entirely evidence-based approach to every clinical datum. I certainly commend Michel for the breadth of his medical literacy, as reflected by the citations in his letter. However, the review article by Olkinuora1 cites a Finnish study that appears to support our viewpoint. It states that “for men, the number of days of hospital care due to alcohol and the number of visits to outpatient clinics for the same reason were the highest among unskilled workers, followed by painters, seamen, and construction workers.” Likewise, having cared for many merchant seamen, I believe it would be a disservice to them to overlook the possibility of high-risk behavior during shore leave and its implications for the contraction of a variety of diseases.2

It goes without saying that consideration of any of these disorders would never alter a personal and sympathetic approach to care. Payne provides an excellent example of how a sensible anecdote can help in diagnosis, and I am grateful for her observation.

Lawrence M. Tierney, Jr., M.D.
University of California, San Francisco, San Francisco, CA 94121

2 References

1. 1

   Olkinuora M. Alcoholism and occupation. Scand J Work Environ Health 1984;10:511-515
   CrossRef | Web of Science | Medline

2. 2

   Towianska A, Dabrowski J, Rozlucka E. HIV antibodies in seafarers, fishermen and in other population groups in the Gdansk Region (1993-1996). Bull Inst Marit Trop Med Gdynia 1996;47:67-72
   Medline