The under- and overrecognized, and the elephant in the room

Brian F. Mandell

doi:10.3949/ccjm.87b.04020

In this issue of the Journal we have a paper reminding readers of an uncommon clinical syndrome that is underrecognized, and a second paper discussing a very common clinical syndrome that is likely overdiagnosed and over-reated.

Those of you who regularly read CCJM know of my preoccupation with the value of the patient’s history and the physical examination in directing the diagnostic evaluation as well as my enormous respect for clinicians who have honed those skills. The “Clinical Picture” section was born from my desire to remind us all of the power of observation by highlighting images from clinical and sometimes radiographic and other examinations.

In this issue, Van Twist et al (page 194) present a picture of a patient with recurrent palmar surface finger hematomas (Achenbach syndrome). While I have seen and descriptively diagnosed this in 1 friend and several patients, ending the evaluation of their previously suspected vasculitis or Raynaud syndrome, I was not aware of its eponymous designation or of any literature describing small case series. I suspect that I may not be alone in this regard, and I thus appreciate the authors’ submission.

At the other end of the spectrum, Young et al (page 223) discuss gastroesophageal reflux disease (GERD), an entity diagnosed by all of us in the clinic and at home and social gatherings. The disease is so common that we will usually be diagnosing it correctly even without taking a careful history and pointedly revisiting the diagnosis after a pre-defined therapeutic trial with a proton pump inhibitor (PPI). But as the authors point out, there are specific features of the history that should direct us to considering an alternative approach to long-term PPI therapy or to recognizing when PPI therapy has failed, and why (eg, when exactly is the patient taking the medication).

As we are all in the midst of the amazingly jarring and outright scary COVID-19 pandemic, I realize how mundane a discussion of heartburn is. Yet in a way, it is the ability to recognize the pine cones without losing our vision of the forest that characterizes us as internists and keeps us professionally on course.

Hopefully, this pandemic will pass relatively soon, and our health systems and global connections will be stronger.

Be safe.