To the Editor In their article, Konikkara et al1 presented a comprehensive and timely report of a 62-year-old man with a systemic illness and skin lesion. The postmortem diagnosis was intravascular lymphoma. While I applaud their detailed description of a rare or underdiagnosed disorder, I am concerned about their clinical strategy. Their patient was seen by multiple specialists, underwent extensive imaging including computed tomography of the chest and abdomen and magnetic resonance imaging of the brain, and finally underwent a brain biopsy, which was not diagnostic. During this extensive diagnostic workup, the patient’s skin lesion did not attract his treating physicians’ attention. It is understandable that physicians may not diagnose rare conditions or misdiagnose those with vague or mild symptoms. However, the patient reported on by Konikkara et al had a well-described undiagnosed skin lesion and marked constitutional symptoms. Therefore, a skin biopsy was the most important diagnostic test. There are reports indicating that significant errors in dermatologic diagnosis may occur because of failure to perform a prompt skin biopsy.2 As the authors of the article also emphasized, in this patient, performance of a skin biopsy on cutaneous lesions and even on normal-appearing skin could have facilitated the diagnosis and led to appropriate therapy and better prognosis.3,4 Therefore, in agreement with the authors, I believe early diagnosis of this patient was possible, if a simple skin biopsy was performed. Although it is not clear why the patient’s physicians dismissed a simple skin biopsy in favor of a brain biopsy, I have a suspicion that it is the ongoing and sad story that, in today’s era, medical decision making more and more is being governed by dependence on neuroimaging, which may not achieve a high level of diagnostic certainty in complex neurological situations, such as the one presented here. In making a clinical diagnosis, neurologists sometimes are influenced more by the perceived diagnosis by magnetic resonance imaging than by their own clinical judgment. In my opinion, unless there is a significant change in both training and practice of bedside medicine to guide the current students and residents to the roles and responsibilities of independent clinical diagnostician, this potentially unproductive variation in clinical strategies will continue.
Roohi F. Diagnosis of Intravascular Lymphoma. JAMA Neurol. 2013;70(7):941. doi:10.1001/jamaneurol.2013.307