Zebra Card GE-000: great imitators

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	Great imitators
	Differential Diagnosis	[Top] [Nav]
	Infections: syphilis, subacute bacterial endocarditis, Whipple disease, tuberculosis, disseminated mycoses, Lyme disease, brucellosis, Intravascular disease: subacute bacterial endocarditis, cardiac myxoma, vasculitis, mycotic aneurysm, aortic dissection, atheroemboli Masses and miscellany: renal cell carcinoma, lymphoma, leukemia, amyloidosis, poisoning, others
	Discussion -- not available online	[Top] [Nav]

Erratum in printed version

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Carbon monoxide omitted from index.

Notes

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In the 1980s, medical computer scientists began compiling huge databases of diseases and their symptoms and signs. These databases attempted to be complete because the aim was to build computer programs able to perform diagnosis at or beyond human abilities. Question: According to these databases, which diseases have the most different manifestations? Here is one answer, from the QMR database in 1989:

Disease	Number of findings in QMR
aortic dissection	215
non-Hodgkin malignant lymphoma	211
systemic Hodgkin disease	205
acute intermittent porphyria	178
multiple sclerosis	176
Wegener granulomatosis	173
Henoch-Schonlein syndrome	168
chronic myelocytic leukemia in myeloblastic criteria	166
acute pancreatitis	164
disseminated histoplasmosis	163

Thanks to Dr. Greg Cooper for the data.

	Update Comments	[Top] [Nav]
	"Almost any symptom of [SBE] may be its first manifestation, particularly cardiac weakness, urinary symptoms, pulmonary symptoms, headache, vertigo or digestive disturbances." [102] Yes, this is the infamous discredited John Darsee. Hard to see how he could fudge a review article, though. [118] Cites 4 CPCs on cholesterol embolism in the New England Journal of Medicine: 25-1967, 51-1973, 33-1974, and 2-1991. [121] "Renal cell carcinoma has a tendency to metastasize widely before giving rise to any local symptoms. It has been known to metastasize to almost every organ of the body and for these reasons it is classified as a great mimic in medicine, having been confused at one time or another with almost every disease." [123] "Renal-cell carcinoma, known as the `internist's tumor' because of the variety of its presenting symptoms, certainly can cause anemia.... Known as the great masquerader because of the protean manifestations at the time of presentation, renal-cell carcinoma can cause multiple paraendocrine syndromes and extrarenal manifestations." [124] Lists sarcoidosis, vasculitis, systemic lupus, and Lyme disease as the 4 imitators. [127] Longer list of multiple sclerosis imitators, taken from a monograph. [128] This section is hopelessly dated: recent improvements in the therapy of AIDS will no doubt change, yet again, the natural history of syphilitic co-infection. [130] Says "seronegative" is less accurate than "delayed conversion to seropositivity." [135] Pheochromocytoma as "the great mimic among hypertensive disorders." [136] "Behçet's syndrome is a protean disorder with a wide spectrum of clinical manifestations. [We suggest] consideration of the syndrome in nearly all cases of vaguely-defined symptomatology." [139] Post-traumatic stress disorder "can unfortunately mimic virtually any condition in psychiatry." [140]

Footnotes in Print Edition

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	(01)	Modern Clinical Syphilology. 3rd ed. Stokes JH, et al. Philadelphia: Saunders, 1944: 41.
	(02)	[This footnote was a comment, not a reference.]
	(03)	Endocarditis. Sande M, et al. New York: Churchill-Livingstone, 1984: vii.
	(04)	Whipple's Disease. Dobbins WO. Springfield, IL: Thomas, 1987: vii. Amazon.com
	(05)	Differential Diagnosis. 3rd ed. Harvey AM, et al. Philadelphia: Saunders, 1979: 638.
	(06)	Coccidioidomycosis--a great imitator disease [editorial]. Huntington RW Jr. Arch Pathol Lab Med 1986 Mar;110(3):182. Pubmed Similars
	(07)	Preface [to symposium on Lyme disease]. Benach JL. Ann NY Acad Sci. 1988;539:xiii-xiv.
	(08a)	The Nature of Brucellosis. Spink WW. Minneapolis: University of Minnesota Press, 1956: 191.
	(08b)	Treatment of human brucellosis. Smith CC. Scott Med J 1976 Jul;21(3):132-3. Pubmed Similars
	(08c)	Human brucellosis. Young EJ. Rev Infect Dis 1983 Sep-Oct;5(5):821-42. Pubmed+Abstract Similars 10 pages of case reports, each with a commentary.
	(09)	Philip A. Tumulty. Humphries JO. Johns Hopkins Medical Journal. 1975;137:141.
	(10)	Heart Disease. 3rd ed. Braunwald E, et al. Philadelphia: Saunders, 1988: 1470-1473. Amazon.com
	(11)	The spectrum of vasculitis: clinical, pathologic, immunologic and therapeutic considerations. Fauci AS, Haynes B, et al. Ann Intern Med 1978 Nov;89(5 Pt 1):660-76. Pubmed+Abstract Similars
	(12)	Systemic Lupus Erythematosis. Lahita RG, et al. New York: Wiley, 1987: xvii.
	(13)	[This footnote was a comment, not a reference.]
	(14a)	Dissecting aneurysm of the aorta: a review of 505 cases. Hirst AE Jr, Johns VJ, Kime SW. Medicine. 1958;37:217-279.
	(14b)	Ruptured abdominal aneurysms simulating sepsis. Szilagyi DE, et al. Arch Surg. 1965;91:263-275.
	(15)	Case records of the Massachusetts General Hospital. Weekly clinicopathological exercises. Case 30-1986. A 74-year-old man with azotemia, eosinophilia, and peripheral cyanosis and mottling. N Engl J Med 1986 Jul 31;315(5):308-15. Pubmed Similars
	(16)	Renal cell carcinoma: unusual systemic manifestations. Cronin RE, Kaehny WD, et al. Medicine (Baltimore) 1976 Jul;55(4):291-311. Pubmed+Abstract Similars
	(17a)	Occurrence and prognosis of extranodal lymphomas. Freeman C, Berg JW, et al. Cancer 1972 Jan;29(1):252-60. Pubmed Similars
	(17b)	Principles and Practice of Medicine. 22nd ed. Harvey AM, et al. East Norwalk, CT: Appleton & Lange, 1988: vii.
	(18)	Atypical manifestations of leukaemia. Wintrobe MM, Mitchell DM. Quart J Med. 1940;9:67-91.
	(19)	Rare Diseases and Lesions. Bean WB. Springfield, IL: Thomas, 1967: 37.
	(20a)	Subacute carbon monoxide poisoning. Another great imitator. Grace TW, Platt FW. JAMA 1981 Oct 9;246(15):1698-700. Pubmed+Abstract Similars
	(20b)	Adult inorganic lead intoxication: presentation of 31 new cases and a review of recent advances in the literature. Cullen MR, Robins JM, et al. Medicine (Baltimore) 1983 Jul;62(4):221-47. Pubmed Similars
	(21)	Rare Diseases and Lesions. Bean WB. Springfield, IL: Thomas, 1967: 147.
	(22)	Differential Diagnosis. 3rd ed. Harvey AM, et al. Philadelphia: Saunders, 1979: 611-718.
	(23a)	Handbook of Clinical Neurology. Vinken PJ, Bruyn GW. Amsterdam: North Holland: 1985;47:49-78.
	(23b)	Chronic subdural haematoma. Luxon LM, Harrison MJ. Q J Med 1979 Jan;48(189):43-53. Pubmed+Abstract Similars The authors cite Aring CD, J Neurol Neurosurg Psychiat 1960;1:129 as source of the appelation "neurological imitator."
	(23c)	AIDS: the new "great imitator" [editorial]. Sabin TD. J Am Geriatr Soc 1987 May;35(5):467-8. Pubmed Similars
	(24a)	Seronegative secondary syphilis in a patient infected with the human immunodeficiency virus (HIV) with Kaposi sarcoma. A diagnostic dilemma [published erratum appears in Ann Intern Med 1987 Dec;107(6):946] [see comments]. Hicks CB, Benson PM, et al. Ann Intern Med 1987 Oct;107(4):492-5. Pubmed+Abstract Similars
	(24b)	Alteration in the natural history of neurosyphilis by concurrent infection with the human immunodeficiency virus. Johns DR, Tierney M, et al. N Engl J Med 1987 Jun 18;316(25):1569-72. Pubmed+Abstract Similars
	(24c)	The Management of AIDS Patients. Sotos JG. New Engl J Med. 1987;316:632.
	(24d)	Spirochetes in Late Seronegative Syphilis, Penicillin Notwithstanding. Smith JL. Springfield, IL: Thomas, 1969: 343pp.

New References

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	Infective endocarditis
	101.	Infective Endocarditis. 2nd ed. Kaye D (ed). New York: Raven, 1992: 512 pp. Amazon.com
	102.	Subacute Bacterial Endocarditis. Libman E, Friedberg CK. London: Oxford, 1941: 28.
	Whipple disease
	103.	Whipple's disease: clinical, biochemical, and histopathologic features and assessment of treatment in 29 patients. Fleming JL, Wiesner RH, et al. Mayo Clin Proc 1988 Jun;63(6):539-51. Pubmed+Abstract Similars
	104.	Brief report: diagnosis of Whipple's disease by molecular analysis of peripheral blood. Lowsky R, Archer GL, et al. N Engl J Med 1994 Nov 17;331(20):1343-6. Pubmed Similars
	Coccidioidomycosis
	105.	Coccidioidomycosis. Stevens DA. N Engl J Med 1995 Apr 20;332(16):1077-82. Pubmed Similars
	106.	Coccidioidomycosis diagnosed from bone marrow smear. Wolfson D, Lee S. JAMA 1991 Aug 7;266(5):707. Pubmed Similars
	Lyme disease
	107.	Should we try malariotherapy for Lyme disease? [letter]. Heimlich HJ. N Engl J Med 1990 Apr 26;322(17):1234-5. Pubmed Similars
	108.	Borrelia burgdorferi in the nervous system: the new "great imitator". Pachner AR. Ann N Y Acad Sci 1988;539:56-64. Pubmed+Abstract Similars
	109.	Lyme disease: the latest great imitator. Stechenberg BW. Pediatr Infect Dis J 1988 Jun;7(6):402-9. Pubmed+Abstract Similars
	Brucellosis
	110.	Brucellosis. Madkour MM (ed). Boston: Butterworths, 1989: 278 pp. Amazon.com
	111.	Person-to-person transmission of Brucella melitensis [see comments]. Ruben B, Band JD, et al. Lancet 1991 Jan 5;337(8732):14-5. Pubmed+Abstract Similars
	112.	Human brucellosis in Kuwait: a prospective study of 400 cases. Lulu AR, Araj GF, et al. Q J Med 1988 Jan;66(249):39-54. Pubmed+Abstract Similars
	Atrial myxoma
	113.	Left atrial myxoma simulating peripheral vasculitis. Huston KA, Combs JJ Jr, et al. Mayo Clin Proc 1978 Nov;53(11):752-6. Pubmed+Abstract Similars
	114.	Clinical aspects of left atrial myxoma: report of a case simulating subacute bacterial endocarditis and review of 5 cases treated surgically. Mundth ED, Wheeler EO, et al. Ann Thorac Surg 1968 Mar;5(3):255-61. Pubmed Similars
	115.	Right atrial myxoma mimicking a rheumatic disorder. Currey HL, Mathews JA, et al. Br Med J 1967 Mar 4;1(539):547-8. Pubmed Similars
	Systemic lupus erythematosis
	116.	A novel antinuclear antibody associated with a lupus-like paraneoplastic syndrome. Freundlich B, Makover D, et al. Ann Intern Med 1988 Aug 15;109(4):295-7. Pubmed+Abstract Similars
	Mycotic aneurysm
	117.	Case records of the Massachusetts General Hospital. Weekly clinicopathological exercises. Case 18-1989. A 52-year-old woman with left-lower quadrant abdominal pain, fever, and splenic infarcts [see comments]. N Engl J Med 1989 May 4;320(18):1201-6. Pubmed Similars
	Atheroemboli
	118.	Cholesterol embolism: the great masquerader. Darsee JR. South Med J 1979 Feb;72(2):174-80. Pubmed+Abstract Similars
	119.	A mimic of vasculitis. Olin JW. Cleve Clin J Med 1992 Jan-Feb;59(1):96-7. Pubmed Similars
	120.	Multiple cholesterol emboli syndrome. Bowel infarction after retrograde angiography. Hendel RC, Cuenoud HF, et al. Arch Intern Med 1989 Oct;149(10):2371-4. Pubmed+Abstract Similars
	121.	Clinical problem-solving: one more hypothesis [letter; comment]. Hauben M. N Engl J Med 1993 Dec 9;329(24):1821. Pubmed Similars
	122.	Cholesterol crystal embolization in the Netherlands [see comments]. Moolenaar W, Lamers CB. Arch Intern Med 1996 Mar 25;156(6):653-7. Pubmed+Abstract Similars
	Renal cell carcinoma
	123.	Renal cell carcinoma: natural history and results of treatment. Patel NP, Lavengood RW. J Urol 1978 Jun;119(6):722-6. Pubmed+Abstract Similars
	124.	Case records of the Massachusetts General Hospital. Weekly clinicopathological exercise. Case 38-1989. A 19-year-old man with fever, abdominal pain, anemia, and a left renal mass [see comments]. N Engl J Med 1989 Sep 21;321(12):813-23. Pubmed Similars
	Extramedullary hematopoiesis
	125.	Extramedullary hematopoiesis manifesting as a symptomatic pleural effusion. Bartlett RP, Greipp PR, et al. Mayo Clin Proc 1995 Dec;70(12):1161-4. Pubmed+Abstract Similars
	Neurological imitators
	126.	Sarcoidosis of the nervous system. A clinical approach. Sharma OP, Sharma AM. Arch Intern Med 1991 Jul;151(7):1317-21. Pubmed+Abstract Similars
	127.	Diseases that mimic multiple sclerosis. Scott TF. Postgrad Med 1991 Jun;89(8):187-91. Pubmed+Abstract Similars
	128.	Multiple sclerosis: update in diagnosis and review of prognostic factors. Swanson JW. Mayo Clin Proc 1989 May;64(5):577-86. Pubmed+Abstract Similars
	129.	Subdural hematoma. A retrospective study of the 'great neurologic imitator'. Black DW. Postgrad Med 1985 Jul;78(1):107-11, 114. Pubmed+Abstract Similars
	Syphilis
	130.	This section is hopelessly dated: recent improvements in the therapy of AIDS will no doubt change, yet again, the natural history of syphilitic co-infection.
	131.	False negative screening tests for syphilis in pregnant women [letter]. Berkowitz KM, Stampf K, et al. N Engl J Med 1990 Jan 25;322(4):270-1. Pubmed Similars
	132.	Congenital syphilis presenting in infants after the newborn period [see comments]. Dorfman DH, Glaser JH. N Engl J Med 1990 Nov 8;323(19):1299-302. Pubmed+Abstract Similars
	133.	Effect of human immunodeficiency virus (HIV) infection on the course of syphilis and on the response to treatment. Musher DM, Hamill RJ, et al. Ann Intern Med 1990 Dec 1;113(11):872-81. Pubmed+Abstract Similars
	134.	Altered clinical presentation of early syphilis in patients with human immunodeficiency virus infection. Hutchinson CM, Hook EW 3rd, et al. Ann Intern Med 1994 Jul 15;121(2):94-100. Pubmed+Abstract Similars
	135.	"Seronegative" syphilis in AIDS [letter; comment]. Zalka A, Grossman ME, et al. Ann Intern Med 1991 Mar 15;114(6):521-2. Pubmed Similars
	Others
	136.	Pheochromocytoma. DeCourcy JL. Am J Surg. 1953;86:37-44.
	137.	Depression, the great simulator. Tingle D, et al. Hospital Physician. 1989;25(12):51-54.
	138.	High altitude illness. Disease with protean manifestations. Houston CS. JAMA 1976 Nov 8;236(19):2193-5. Pubmed Similars
	139.	Polyarthritis in Behçet's multiple symptom complex. Strachan RW, Wigzell FW. Ann Rheum Dis. 1963;22:26-35.
	140.	Achilles in Vietnam: Combat Trauma and the Undoing of Character. Shay J. New York: Simon & Schuster, 1994: 169. Amazon.com

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