Correspondence

The Missing Piece

N Engl J Med 2007; 356:873-874February 22, 2007

Article

To the Editor:

Robertson et al. (Nov. 2 issue)1 discuss the case of a young man with exertional dyspnea, cough, and increasing pain in the right lower quadrant, which was traced to a subcutaneous nodule. Instead of thoracentesis, computed tomography of the chest, abdomen, and pelvis and bronchoscopy, would a more straightforward and less invasive approach have been to perform a biopsy of the subcutaneous nodule? This approach would have offered the same diagnosis — acute paragonimiasis — at less expense and risk to the patient.

Russell R. Ryan, M.D.
Surgical Specialists of the North Shore, Salem, MA 01970

1 References

1. 1

   Robertson KB, Janssen WJ, Saint S, Weinberger SE. The missing piece. N Engl J Med 2006;355:1913-1918
   Full Text | Web of Science | Medline

Author/Editor Response

I agree that a biopsy of the subcutaneous nodule in the abdominal wall would have been a less invasive, less expensive, and more efficient diagnostic strategy. However, in cutaneous paragonimiasis, skin findings can change frequently, even on a daily basis, owing to subcutaneous migration of the parasite.1 In our patient, the nodule shifted early on in his hospitalization and became much less distinct. Therefore, although it was considered, a biopsy was not performed because it was thought to be of low diagnostic yield at the time.

Kathryn B. Robertson, M.D.
University of Colorado Health Sciences Center, Denver, CO 80262
kathryn.robertson@uchsc.edu

1 References

1. 1

   Mizuki M, Mitoh K, Miyazaki E, Tsuda T. A case of Paragonimiasis westermani with pleural effusion eight months after migrating subcutaneous induration of the abdominal wall. Nihon Kyobu Shikkan Gakkai Zasshi 1992;30:1125-1130
   Medline