Skip to main content

Advertisement

SpringerLink
Log in

Plurality Over Parsimony: When Two Diagnoses Are More Likely Than One

  • Exercises in Clinical Reasoning
  • Published:
Journal of General Internal Medicine Aims and scope Submit manuscript

This is a preview of subscription content, log in via an institution to check access.

Access this article

Log in via an institution

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Institutional subscriptions

Figure 1
Figure 2
Figure 3
Figure 4

References

  1. Greenberg JD, et al. Association of methotrexate and tumour necrosis factor antagonists with risk of infectious outcomes including opportunistic infections in the CORRONA registry. Ann Rheum Dis. 2010;69:380–386.

    Article  CAS  PubMed  Google Scholar 

  2. Gutierrez-Ureña S, Molina JF, García CO, Cuéllar ML, Espinoza LR. Pancytopenia secondary to methotrexate therapy in rheumatoid arthritis. Arthritis Rheum. 1996;39:272–276.

    Article  PubMed  Google Scholar 

  3. Ohosone Y, et al. Clinical characteristics of patients with rheumatoid arthritis and methotrexate induced pneumonitis. J Rheumatol. 1997;24:2299–2303.

    CAS  PubMed  Google Scholar 

  4. Mori S, et al. Factors Associated with Myelosuppression Related to Low-Dose Methotrexate Therapy for Inflammatory Rheumatic Diseases. PLoS ONE. 2016;11:e0154744.

    Article  PubMed  PubMed Central  Google Scholar 

  5. Mehdi SR, Bhatt MLB. Metastasis of Solid Tumors in Bone Marrow: A Study from Northern India. Indian J Hematol Blood Transfus. 2011;27:93–95.

    Article  PubMed  PubMed Central  Google Scholar 

  6. Ellis SM, Hansell DM. Imaging of Non-tuberculous (Atypical) Mycobacterial Pulmonary Infection. Clin Radiol. 2002;57:661–669.

    Article  CAS  PubMed  Google Scholar 

  7. Prince DS, et al. Infection with Mycobacterium avium Complex in Patients without Predisposing Conditions. N Engl J Med. 1989;321:863–868.

    Article  CAS  PubMed  Google Scholar 

  8. Carmier D, et al. Serious bronchopulmonary involvement due to chronic lymphocytic leukaemia. Eur Respir Rev. 2013;22:416–419.

    Article  PubMed  PubMed Central  Google Scholar 

  9. Rahul E, et al. Large granular lymphocytic leukemia: a brief review. Am J Blood Res. 2022;12:17–32.

    CAS  PubMed  PubMed Central  Google Scholar 

  10. Fuhrman C, et al. Spectrum of CD4 to CD8 T-Cell Ratios in Lymphocytic Alveolitis Associated with Methotrexate-induced Pneumonitis. Am J Respir Crit Care Med. 2011;164:1186–1191.

    Article  Google Scholar 

  11. World Health Organization (WHO) Classification of Tumours Editorial Board. WHO Classification of Tumours of Haematopoietic and Lymphoid Tissues (beta version ahead of print). vol. 11 (International Agency for Research on Cancer Press, 2022).

  12. Nowakowski GS, et al. Percentage of Smudge Cells on Routine Blood Smear Predicts Survival in Chronic Lymphocytic Leukemia. J Clin Oncol. 2009;27:1844–1849.

    Article  PubMed  PubMed Central  Google Scholar 

  13. Loughran TP, et al. Leukemia of Large Granular Lymphocytes: Association with Clonal Chromosomal Abnormalities and Autoimmune Neutropenia, Thrombocytopenia, and Hemolytic Anemia. Ann Intern Med. 1985;102:169–175.

    Article  PubMed  Google Scholar 

  14. Senthil R, Visakh RA, Pratap T, Mahadevan P, Gangadharan VP. Atypical Presentation of T-Cell Large Granular Lymphocytic Leukemia Mimicking Pleural Malignancy on 18F-FDG PET/CT. Clin Nucl Med. 2019;44:e296.

    Article  PubMed  Google Scholar 

  15. Patatanian E, Thompson DF. A Review of Methotrexate-Induced Accelerated Nodulosis. Pharmacother J Hum Pharmacol Drug Ther. 2002;22:1157–1162.

    Article  CAS  Google Scholar 

  16. Chater N, Vitányi P. Simplicity: a unifying principle in cognitive science? Trends Cogn Sci. 2003;7:19–22.

    Article  PubMed  Google Scholar 

  17. Redelmeier DA, Tan SH, Booth GL. The Treatment of Unrelated Disorders in Patients with Chronic Medical Diseases. N Engl J Med. 1998;338:1516–1520.

    Article  CAS  PubMed  Google Scholar 

  18. Kelly J. The Diagnostic Approach in Complex Patients: Parsimony or Plenitude? Am J Med. 2021;134:11–12.

    Article  PubMed  Google Scholar 

  19. Sokol L, Loughran TP. Large granular lymphocyte leukemia. Oncologist. 2006;11:263–273.

    Article  CAS  PubMed  Google Scholar 

Download references

Acknowledgements:

We give our sincere appreciation and gratitude to our patient for her consent to the publication of this manuscript. We would also like to thank Dr. Loughran for his expert guidance on LGL leukemia, a disease which he first described and has since performed landmark research to further characterize.

Author information

Authors and Affiliations

  1. University of Virginia School of Medicine, Charlottesville, VA, USA

    Jasraj S. Raghuwanshi BS

  2. Division of Hematology & Oncology, Department of Medicine, University of Virginia Health System, Charlottesville, VA, USA

    Nathan Roberts MD, Thomas P. Loughran, Jr. MD & Firas El Chaer MD

  3. Division of Clinical Pathology, Department of Pathology, University of Michigan Health System, Ann Arbor, MI, USA

    Mark Girton MD

  4. Division of General, Geriatric, Palliative and Hospital Medicine, Department of Medicine, University of Virginia Health System, Charlottesville, VA, USA

    Glenn Moulder MD

Authors
  1. Jasraj S. Raghuwanshi BS
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Nathan Roberts MD
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Thomas P. Loughran, Jr. MD
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Firas El Chaer MD
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Mark Girton MD
    View author publications

    You can also search for this author in PubMed Google Scholar

  6. Glenn Moulder MD
    View author publications

    You can also search for this author in PubMed Google Scholar

Contributions

• Jasraj S. Raghuwanshi, BS—inpatient medical student for the patient; responsible for preparing first draft of the manuscript, elaborating on clinical reasoning strategy used in this case, literature review, and accessing and compiling lab results/radiological images.

• Nathan Roberts, MD—inpatient hematologist-oncologist for the patient, responsible for acquiring and reviewing hematopathological slides and providing interpretation, provided substantial content review and copyediting.

• Thomas P. Loughran, Jr., MD—international expert and first to describe LGL leukemia (Loughran, Jr. et al., 1985), advised on clinical presentation, symptomatology, and prognosis of LGL leukemia and its subtypes.

• Firas El Chaer, MD—outpatient hematologist for the patient, provided key details on follow-up and resolution of symptomatology following discontinuation of methotrexate, copyediting.

• Mark Girton, MD—hematopathology and lab medicine expert; advised on spread of hematolymphoid malignancies, subtypes of LGL leukemia by flow cytometry phenotype and prognosis, 2016 WHO diagnostic and clinical criteria for LGL leukemia, atypical nature of the lymphocytosis in this patient’s presentation, and accurately reporting lab results (CBC, BMP, flow cytometry); provided substantial content review and copyediting.

• Glenn Moulder, MD—inpatient internist for the patient, responsible for majority of inpatient workup and clinical reasoning, highlighted unique presentation and diagnostic challenge with concurrent methotrexate pneumonitis and LGL leukemia not yet described in the literature, copyediting.

Corresponding author

Correspondence to Jasraj S. Raghuwanshi BS.

Ethics declarations

Conflict of Interest:

The authors declare that they do not have a conflict of interest.

Additional information

Publisher's Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Raghuwanshi, J.S., Roberts, N., Loughran, Jr., T. et al. Plurality Over Parsimony: When Two Diagnoses Are More Likely Than One. J GEN INTERN MED 39, 1257–1263 (2024). https://doi.org/10.1007/s11606-023-08585-7

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s11606-023-08585-7

Search

Navigation