The All-knowing All-seeing Radiologist

November 24, 2014

Radiology can’t be expected to save the day every time.

Over the years I have (tongue-in-cheek) reminded my clinical colleagues that radiologists are the smartest doctors in the institution because of our requisite knowledge of all kinds of pathophysiology, not just the lesion itself, but also how and in whom it presents. Doesn’t matter if it’s a fetus, neonate, infant, child, teen, adult, or the elderly. Doesn’t matter if it’s a male or female. Doesn’t matter if it’s the foot, thigh, abdomen, chest, head, or neck. For many radiologists across the country, we are just expected to know and generally we do. Few physicians have the breadth of knowledge we need to effectively function on a daily basis. So I like to remind my friendly colleagues of that whenever I can, all in good-natured fun. Unexpectedly this proclamation came back to me this past week in an interesting idea exchange.

We’d had a case of primary pulmonary and pleural tuberculosis evade diagnosis for weeks, despite multiple hospitalizations and many different physicians, including family medicine residents and program director, hospitalists, and infectious disease. Initially, there was a garden-variety RLL consolidative pneumonia in a 26-year-old male. Then the typical “lost to follow up” period for six months and then resurfacing with ipsilateral persistent pneumonia, single rib fracture, small pleural effusion, and pneumothorax after a fall. Findings were thought to be post-traumatic, but the persistent pneumonia was revealed after lung re-expansion. Three blood cultures were positive for Staph aureus, thought to explain subsequent cavitation two weeks later. Interval CT showed empyema, subsequently drained and cultured, also with S. aureus results. Patient finally improved on IV antibiotics and was eventually discharged.

Patient returned after his meds ran out and repeat CXR showed persistent or worsening pneumonia. Repeat cultures again showed S. aureus. CT showed increasing parietal and visceral pleural thickening, now with hydropneumothorax. Another chest tube placed, but now someone finally considered the possibility of TB, so AFB staining was done and thankfully the final diagnosis was forthcoming.[[{"type":"media","view_mode":"media_crop","fid":"29724","attributes":{"alt":"Ken Keller, MD","class":"media-image media-image-right","id":"media_crop_3165135785173","media_crop_h":"0","media_crop_image_style":"-1","media_crop_instance":"3098","media_crop_rotate":"0","media_crop_scale_h":"0","media_crop_scale_w":"0","media_crop_w":"0","media_crop_x":"0","media_crop_y":"0","style":"height: 184px; width: 160px; border-width: 0px; border-style: solid; margin: 1px; float: right;","title":" ","typeof":"foaf:Image"}}]]

So, now fast-forward to the CPC presentation a few weeks ago, fully three months after the diagnosis had been made with the patient finally making meaningful clinical improvement. The second-year resident is presenting the case in detail to all the medical students and other residents, as well as a few attending physicians who decided to drop in for the luncheon discussion. I dovetail in discussion of the imaging findings at the appropriate time during the overall presentation. Then there were lots of questions about how could the diagnosis have been made sooner, why wasn’t the ID department clued into TB sooner, was the S. aureus just a contaminant or was there co-existing Staph and TB pneumonia, clinical and imaging differences between primary and reactivation TB, etc.

Finally one of the more senior attendees whom I’ve known for 25 years says to me “Doctor, why didn’t radiology suggest this was TB from the outset? I thought you guys knew everything about everything?” The entire audience chuckles as I scramble for a response. I deadpanned, “Would you like us to suggest TB on every consolidative pneumonia we see? Imagine the firestorm that would follow. We all need to have a higher index of suspicion, particularly the docs taking care of the patient, since they know the history and specifics of the case. Radiology can’t save the day every time.”

He smiled with his one-word response “Touché.”