Clinical problem-solving. Red snapper or crab?

Our plain-English summary of Clinical problem-solving. Red snapper or crab?, by P.B. Cornia, B.A. Lipsky, G. Dhaliwal, et al (The New England Journal of Medicine, 2004).

The study

• Authors: P.B. Cornia, B.A. Lipsky, G. Dhaliwal, S. Saint
• Journal: The New England Journal of Medicine
• Published: 2004;350(14):1443-8
• Type of article: Case report
• Cited by: 1 article, as counted by NIH iCite
• Read it: PubMed · Publisher

In plain English

This article was a case report in a clinical problem-solving series. An expert clinician reasoned through a real patient's case in stages, and the authors then added commentary. The patient was a 68-year-old man originally from the Philippines who had served in the Navy for 20 years and then worked as a custodian. He presented with three months of worsening breathlessness, weight loss, night sweats and abdominal bloating. Tests showed a bloody right-sided pleural effusion and nodules on the omentum, and no malignant cells were seen in the fluid. A pleural biopsy was at first misread as metastatic prostate cancer. Biopsies taken at laparoscopy led to the diagnosis of malignant mesothelioma, five months after he first presented. On further questioning, he reported continual exposure to asbestos-covered pipes in the Navy, while scraping and repainting them and while working below deck as a cook. The authors wrote that the delay probably did not alter the outcome but may have been avoidable. The authors concluded that careful history taking and physical examination usually lead to the correct diagnosis, especially in perplexing cases.

We wrote this plain-English summary from the full article with the help of AI, and a second AI model checked each sentence against the article. It is not the authors' wording; the abstract and the article are their own account.

What the study did and found

• Design: Case report (single patient), presented as a clinical problem-solving exercise with an expert discussant and authors' commentary
• Who was studied: One 68-year-old man originally from the Philippines with three months of increasing breathlessness on exertion, breathlessness lying flat, 7 kg weight loss, night sweats and abdominal bloating. He had a history of prostate cancer treated 15 years earlier and a positive tuberculin skin test.
• Exposure: Navy service for 20 years, then work as a custodian. On further questioning he reported continual exposure to asbestos-covered pipes while scraping and repainting them and while working below deck as a cook. No fiber type was given.
• Main results:
  • Chest CT showed a right-sided pleural effusion with no pleural plaques.
  • Abdominal CT showed normal organs but multiple enhancing omental nodules.
  • One liter of bloody pleural fluid was removed. Cytology showed mesothelial cells without malignant features.
  • Tissue from pleuroscopy was initially misread as metastatic carcinoma consistent with prostate cancer. The final interpretation was a fibrin clot with benign-appearing mesothelial cells.
  • Exploratory laparoscopy found an omentum caked with nodular plaques. Pathological evaluation of the biopsy specimens by immunocytochemistry and electron microscopy showed malignant mesothelioma.
  • Five months passed between the patient's first presentation and the correct diagnosis.
  • The authors judged that the delay probably did not alter the outcome but may have been avoidable.
• The authors' conclusion: The authors concluded that careful history taking and physical examination usually lead to the correct diagnosis, especially in perplexing cases.

Topics

The National Library of Medicine indexes this study under subjects our site covers: Mesothelioma, Peritoneal mesothelioma.

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• Primary omental mesothelioma: a rare but important differential diagnosis in previous asbestos exposure — A. Harb, E. King, et al. (2010)
• Neoplastic and inflammatory processes of the peritoneum, omentum, and mesentery: diagnosis with CT — J.E. Hamrick-Turner, M.V. Chiechi, et al. (1992)
• CT-guided core-needle biopsy in omental pathology — F. Pombo, E. Rodriguez, et al. (1997)
• Primary malignant mesothelioma of the greater omentum: report of a case — Y.C. Liu, Y.L. Kuo, et al. (2004)
• Asbestos in extrapulmonary sites: omentum and mesentery — R.F. Dodson, M.F. O'Sullivan, et al. (2000)

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