Hematologic disorders are the most complex of all medical system diseases, with a wide range of diseases and confusing clinical manifestations. Both the causes and the pathological mechanisms of their development are extremely complex. From relatively “macroscopic” biological and physical factors to microscopic cellular and molecular levels, from genetic to acquired factors, almost everything is included. The clinical manifestations and pathological classification are even more complex and varied. Hematologic diseases are usually not common, and some of them are rare or even rare diseases. Most of them are unheard of, not to mention the general public, and even non-hematologists and professionals have little or no knowledge of hematologic disorders. As a result, in clinical practice, one or several types of hematologic disorders are easily misdiagnosed as other systems or other specialized diseases in the early or middle stages, leading to treatment failure or even delayed illness, or even serious adverse consequences. The dizziness and palpitations caused by anemia were misdiagnosed as cardiovascular disease, jaundice in hemolytic anemia was misdiagnosed as liver disease, and eosinophilia combined with abdominal pain and leukocytosis was misdiagnosed as infectious disease or even leukemia …… A representative case of misdiagnosis recently encountered is cited for professional discussion. Name: Wei Xiuying Gender: female Age: 42 years old Occupation: farmer Marriage: married Birthplace: Taishan, Guangdong Complaint: fever, cough, dyspnea for more than 1 month, malaise, dizziness with scleral skin yellowing for half a month. History: The patient started to have low to moderate fever with cough, sputum, chest tightness and progressive dyspnea in mid-June 2014, and the symptoms did not improve significantly after taking some cold and fever-reducing drugs by himself. On July 24, 2014, he went to the chest clinic of the local people’s hospital and had a CT scan of the chest + enhancement on the following day. The findings were: patchy solid shadow in the middle lobe of the right lung, multiple enlarged lymph nodes in the hilum, mediastinum and axillae on both sides, most of which were fused. Small nodular hypodense shadow in the spleen, consider small cysts or others. Outpatient ultrasound: liver, bile, spleen and pancreas showed no significant abnormalities. He was admitted to the hospital on July 26, 2014 in bed 3-519 of the Department of Thoracic Surgery, inpatient number: 312008. Admission proposed diagnosis: 1. mediastinal occupancy: lymphoma? 2. superior vena cava syndrome 3. herpes zoster. Physical examination: appearance, mild anemia, no enlarged lymph nodes in the neck, supraclavicular, axilla and groin bilaterally, right transvenous anger, symmetrical thorax without deformity, no rash, subcutaneous hemorrhage and petechiae, normal rib space bilaterally; smooth respiration on chest visual examination, consistent respiratory dynamics bilaterally, no trismus sign on inspiration; normal thoracic expansion on palpation; normal bilateral fibrillation, no pleural friction; no sternum on percussion The sternum is not percussive, both lungs are clear on percussion; the breath sounds of both lungs are normal on auscultation, and no dry or wet bow target is heard in both lungs. Auxiliary examination: 2014-7-24 chest CT examination, the results are as above. Diagnosis and treatment: After admission to the hospital to improve the relevant tests, blood routine: white blood cell count (WBC) 17.19×109/L red blood cell count (RBC) 5.27×1012/L hemoglobin (HGB) 81g/L mean red blood cell volume (MCV) 60.5fL platelet count (PLT) 361×109/L neutrophil percentage (NE%) 81.6% Absolute eosinophil value (EO#) 1.16×109/L Eosinophil percentage (EO%) 6.0% Lymphocyte percentage (LY%) 12.5% Monocyte percentage (MO%) 7.0%. Blood sedimentation (ESR) was 120 mm/h. C-reactive protein (CRP) was 101.94 mg/L. Urinalysis, glucose, lipids, liver function, cardiac enzymatic parameters, blood biochemistry, tumor markers, and hepatitis series showed no significant abnormalities. On 2014-7-29 CT-guided mediastinal mass was punctured for biopsy. Pathology No.: 90382 RESULTS: Microscopically, a small amount of mediastinal mass puncture tissue was seen, with tissue congestion and edema, fibrous tissue hyperplasia, and granulomas composed of multinucleated giant cells, epithelioid cells and lymphocytes, with a large amount of suspected caseous necrosis. Diagnosis: The lesion was considered as mediastinal tuberculosis, please combine with clinical. The pathological specimen was sent to Guangzhou Goldenfield Medical Laboratory Center for consultation. Pathology number: 14123866; Diagnosis: lymphocytic infiltration in fibrous tissue, multifocal epithelioid granulomatous inflammation with coagulative necrosis, consider tuberculosis. Please combine clinical and pathogenetic findings to further confirm the diagnosis. Immunohistochemistry: CD3 scattered +, CD20 scattered +, CD5 scattered +, CK19-, CD117-, TdT-, CD79α scattered +, Ki67 (+20%), CD21FDC network +, CK In the Department of Thoracic Surgery of Taishan People’s Hospital, after anti-inflammatory and symptomatic treatment, the patient’s cough and shortness of breath The symptoms were better than before, and the vital signs were stable, and the patient was discharged on 2014-08-01. The discharge diagnosis was the same as the admission diagnosis. After discharge, he went to the First Affiliated Hospital of Guangzhou University of Traditional Chinese Medicine for one outpatient visit to the Department of Oncology because the pathology of the chest mass puncture biopsy was sent to Guangzhou Jinwei Medical Laboratory Center before the results were available. On 2014-08-15, the patient was admitted to bed 008 of the Department of Internal Medicine, Guangzhou Chest Hospital, hospital number 141600. 2014-08-16 blood count: white blood cell count (WBC) 26.92×109/L red blood cell count (RBC) 4.360×1012/L hemoglobin (HGB) 80.0g/L Mean red blood cell volume (MCV) 56.4fL Platelet count (PLT) 179.0×109/L Neutrophil percentage (NE%) 78.40% Eosinophil absolute value (EO#) 3.82×109/L Eosinophil percentage (EO%) 14.20% Lymphocyte percentage (LY%) 3.50% Monocyte percentage (MO%) ) 2.70%. Sedimentation (ESR) 110 mm/h. 2014-08-18 C-reactive protein (CRP) 149.94 mg/L fungal 1-3-beta-D glucan 133.00 pg/ml calcitoninogen 81.41 ng/ml; negative tuberculosis antibody (Ig-G) negative Mycoplasma pneumoniae antibody (MPP); hepatitis B surface antigen, hepatitis C virus antibody, syphilis Hepatitis B surface antigen, hepatitis C virus antibody, syphilis antibody and HIV antibody and antigen test were all negative. Blood glucose, blood lipids, liver function, cardiac enzymatic index, blood biochemistry, tumor markers, and hepatitis series were not significantly abnormal. 2014-08-19 Chest radiograph (DR) (image number: 440823) examination report: 1, double lung shadow, consider the possibility of tuberculosis; right middle lung lobe containing air incomplete, endothelial tuberculosis to be excluded. Further CT examination is recommended for consultation. 2. Widening of mediastinum and thickening of both pulmonary hilum, considering lymph node tuberculosis. ECG examination: 1, sinus tachycardia 2, occasional premature ventricular beats 3, T-wave changes; 2014-08-19 mucus sputum smear fluorescence staining: found Mycobacterium 1+ (molecular biotechnology is recommended to identify TB bacteria and drug resistance test). No significant abnormalities in liver, gallbladder and spleen ultrasound, bilateral kidney ultrasound, uterine adnexal ultrasound and cardiac ultrasound. Urinalysis, glucose, lipids, liver function, cardiac enzymatic index, blood biochemistry, tumor markers, and hepatitis series were not significantly abnormal. 2014-08-22 Chest CT scan (image number: 110634): considered with medical history: bilateral pulmonary tuberculosis with cervical, mediastinal, and hilar lymph node enlargement (partial calcification) and bilateral pleural effusion. During hospitalization, clinical symptoms gradually improved after 4 weeks of combined anti-TB and symptomatic and supportive treatment. 2014-09-05 Chest CT plain scan + 3D reconstruction: combined with medical history, consider: bilateral pulmonary tuberculosis with enlarged lymph nodes in the neck, mediastinum, hilar, and right axilla (partial calcification) Review, compare with 2014-08-21 CT film, there is absorption of bilateral lung lesions, mediastinal lymph nodes are slightly smaller than before, bilateral pleural The rest was generally similar. 2014-09-23 Mycobacterium sputum identification (No: 20140818JHJ000036) lab serial number: 1408187 result: Mycobacterium tuberculosis, DR examination (image number: 446073) report: combined with medical history and former CT film consider: double pulmonary tuberculosis with mediastinal and hilar lymph node enlargement (partial calcification), compare with 2014-08-19 film: right slightly thickened localized lesions in the lower part, with absorption of the remaining lung lesions, mediastinal mass shadow and bilateral pulmonary hilar shrinkage compared to the previous one. 2014-09-26 bone marrow smear examination report: hyperplasia active bone marrow image, please combine with the clinical. However, since October 2, the patient gradually developed fever, scleral and skin jaundice, yellow urine, poor nausea, abdominal pain and mental fatigue. On 2014-10-02 urinalysis + urine sediment: bilirubin (BIL) 2+ protein (PRO) 1+, the rest are negative. Serum amylase (AMY) 29.00 IU/L 2014-10-03 Calcitoninogen 7.78ng/ml 2014-10-04 Blood count: white blood cell count (WBC) 28.53×109/L red blood cell count (RBC) 2.970×1012/L hemoglobin (HGB) 59.0g/L mean red blood cell volume (MCV) 66.0fL Platelet count (PLT) 159.0×109/L Neutrophil percentage (NE%) 74.60% Absolute eosinophil value (EO#) 1.14×109/L Eosinophil percentage (EO%) 4.0% Lymphocyte percentage (LY%) 12.9% Monocyte percentage (MO%) 2.60%. 2014-10 -04 liver function: glutamate transaminase (ALT) 96.0 U/L glutathione transaminase (AST) 74.0 U/L total bilirubin (TBIL) 217.60umol/L direct bilirubin (DBIL) 186.10umol/L adenosine deaminase (ADA) 13.0u/L total protein (TP) 74.7g/L albumin (ALB) 27.1g /L 2014-10-04 CT plain scan of upper abdomen + enhancement + 3D reconstruction: nodular shadow at the anterior margin of the spleen, considering the possibility of parasplenium, suggesting review and observation; the remaining CT scan of upper abdomen did not show any abnormality. The patient was considered to have drug-related hepatitis caused by anti-TB drugs, so he was transferred to bed 0614 of the Department of Critical Care Hepatology, Guangzhou Eighth People’s Hospital (Infectious Disease Hospital) on 2014-10-05, hospitalization number: 0000161146. 103/53mmHg On examination, he saw moderate yellowing of the skin and mucous membranes, yellowing of the sclera, enlarged lymph nodes could be found in the left neck and axilla, no pressure pain, the pupils were round, and the reflex to light was sensitive. The respiratory sounds of both lungs were clear, and no dry and humid 扌ﻚつΣ烈簟P穆烧耄靼昴で次偶安±硇栽右簦扌陌Σ烈簟8共科饺恚細共可钛雇佣矗共课薨椋纹逾逾逾啊D剖饕跣裕銮禱捱矗贫宰並且 sticky跣裕γ粽！K轮薷≈住 The hospital 2014-10-05 Blood count: white blood cell count (WBC) 33.13×109/L Red blood cell count ( RBC) 2.93×1012/L Hemoglobin (HGB) 58.00g/L Mean red blood cell volume (MCV) 63.1fL Platelet count (PLT) 182.00×109/L Neutrophil percentage (NE%) 86.7% Eosinophil absolute value (EO#) 0.39×109/L Eosinophil percentage (EO%) 1.20% Percentage of lymphocytes (LY%) 7.60% Percentage of monocytes (MO%) 4.40%. Sedimentation (ESR) 62mm/h. Calcitoninogen 0.888ng/ml; 2014-10-05 Liver function: glutathione aminotransferase (ALT) 95U/L glutamic oxalacetic aminotransferase (AST) 44U/L total bilirubin (TBIL) 172.59umol/L direct bilirubin (DBIL) 115.21umol/L indirect bilirubin (IBili) 57.38umol/L adenosine deaminase (ADA) 13.0u/L total protein (TP) 75g/L albumin (ALB) 25g/L globulin (GLB) 50.00g/L albumin/globulin 99 (A/G) 0.50 alkaline phosphatase (ALP) 189U/U total bile acids (TBA) 85.36 umol/L urine routine: bilirubin (BIL) 2+ Urinary bilirubin (URO) negative 2014-10-07 12:11 Blood routine: white blood cell count (WBC) 49.02×109/L red blood cell count (RBC) 2.97×1012/L hemoglobin (HGB) 59.00 g/L mean red blood cell volume (MCV) 66.0 fL platelet count (PLT) 154.00× 109/L Neutrophil percentage (NE%) 75.5% Absolute eosinophil value (EO#) 5.94×109/L Eosinophil percentage (EO%) 12.1% Lymphocyte percentage (LY%) 8.9% Monocyte percentage (MO%) 3.4%. 2014-10-07 19:00 Blood count: white blood cell count (WBC) 56.81×109/L Red blood cell count (RBC) 3.29×1012/L Hemoglobin (HGB) 67.00g/L Mean red blood cell volume (MCV) 66.6fL Platelet count (PLT) 150.00×109/L Neutrophil percentage (NE%) 81.1% Eosinophil absolute value (EO#) 5.62×109/ L Eosinophil percentage (EO%) 9.9% Lymphocyte percentage (LY%) 5.4% Monocyte percentage (MO%) 3.50%. 2014-10-08 Blood count: white blood cell count (WBC) 44.52×109/L red blood cell count (RBC) 2.77×1012/L hemoglobin (HGB) 56.00g/L mean Red blood cell volume (MCV) 66.4fL Platelet count (PLT) 118.00×109/L Neutrophil percentage (NE%) 80.40% Eosinophil absolute value (EO#) 4.76×109/L Eosinophil percentage (EO%) 10.70% Lymphocyte percentage (LY%) 6.20% Monocyte percentage (MO%) 2.60%. Fungal D-glucan (G test) 63.57 pg/ml Gram-negative bacillus antigen (lipopolysaccharide) 68.75 pg/ml; chest radiograph (DR) (radiology number: DX147352) reported: 1. interstitial changes in both lungs and infection in both lungs, with the right middle and lower lungs as the focus; 2. widening of the mediastinum, considered as mediastinal lymph node enlargement. On 2014-10-09, the condition was further aggravated, and the routine blood tests were repeated: white blood cell count (WBC) 37.07×109/L red blood cell count (RBC) 2.38×1012/L hemoglobin (HGB) 48.00g/L mean red blood cell volume (MCV) 66.4fL platelet count (PLT) 141.00×109/L neutrophil Percentage (NE%) 77.40% Absolute eosinophil value (EO#) 4.51×109/L Eosinophil percentage (EO%) 12.20% Lymphocyte percentage (LY%) 7.90% Monocyte percentage (MO%) 2.50%. Anti-nuclear antibody (ANA) negative Hepatitis D antigen and antibody, Hepatitis C IgG antibody, IgM antibody, Hepatitis E IgG antibody, IgM antibody, HIV antibody (HIV-AB) were negative. 2014-10-07 Abdominal ultrasound: 1. No abnormalities in liver, bile, spleen and pancreas; 2. Small amount of ascites 2014-10-09 Bone marrow smear examination ( Classification number: 2014-0105):Combined with clinical considerations: 1, leukemia-like reaction 2, chronic hemolytic reaction. On admission, cefotaxime sulbactam was given to counteract the infection, but the routine blood count was checked for significantly elevated leukocytes (33×109/L). Biapenem was replaced to strengthen the anti-infection. The routine blood tests were repeated and the leukocytes continued to rise (56×109/L). So additional teicoplanin + fluconazole was added to further strengthen the anti-infection. We also asked the hematologist of Guangzhou First People’s Hospital for consultation. Consultation opinion: 1, fever, lymph node enlargement cause to be determined: lymphoma?TB?Rheumatic system disease to be excluded. 2, drug-related liver damage 3, thalassemia. Suggestions: 1. PET-CT should be performed to understand the nature of the lymph nodes, and lymph node biopsy or immunohistochemistry of mediastinal masses can be performed selectively for further examination. 2. Continue symptomatic treatment such as anti-infection and liver protection. 3. The patient’s family expressed understanding of the current situation and requested to continue treatment at an outside hospital and was discharged. Situation at discharge: The patient still had fever in the past three days, with a maximum temperature of 38.4℃ and no significant decrease in the peak compared with the previous one. Physical examination: clear, severe anemic appearance, moderate yellow staining of skin and mucous membranes all over the body, moderate yellow sclera, abdominal muscle tension, right lower abdominal pressure pain with rebound pain, no abdominal mass. The liver was not palpable under the ribs, the spleen was not palpable under the ribs, Murphy’s sign was negative. Bowel sounds were normal, 4 times/min. There was no swelling in both lower limbs. Fluttering tremor was negative. Discharge medical advice: continue treatment outside the hospital. After being discharged from Guangzhou No. 8 Hospital, the patient sought Chinese medicine treatment at the Liver Disease Clinic of the First Affiliated Hospital of Guangzhou University of Traditional Chinese Medicine. After 2 visits, the hepatology specialist prescribed 10 doses of Chinese medicine, mainly to clear heat and dampness and reduce yellowing, but to no avail. At this point, the hepatology specialist recommended a visit to the hematology department. The patient came to our clinic on 2014-10-28. At that time, he was still febrile, with a temperature of 38.4°C, generalized yellowish skin and sclera, and weakness and poor appetite. I read the diagnosis and treatment of the patient in the three aforementioned hospitals and wanted to admit the patient to the ward for further observation and treatment, but I considered that: 1) the patient had active tuberculosis, and according to the Infectious Disease Control Law, general wards cannot admit such infectious patients; 2) the patient had been transferred to three tertiary and specialized hospitals, but the treatment results were not satisfactory, and after more than a month of transferring from one hospital to another, the treatment cost was nearly 100,000. For a farmer’s family, it is really difficult to afford the cost of hospitalization again, so they came to the hematology department with the intention of trying, and probably did not expect too much. Therefore, I could only treat the patient in an outpatient clinic. Based on the medical history and relevant examination results, I considered the diagnosis: 1. hemolytic anemia; 2. drug-related liver damage; 3. secondary eosinophilia. Proposed treatment principle: on the basis of continued anti-TB and anti-infection, hemolysis must first be controlled and eosinophilia gradually reduced. Considering the toxic side effects of the currently popular anti-TB drugs used in the chest hospital, I could only choose anti-TB and anti-infective drugs that are now used sparingly: streptomycin, levofloxacin and amikacin. The jaundice had basically disappeared, the fever was no longer significant, and the spirit and diet had improved. After about 4 weeks of treatment with this regimen, the jaundice completely subsided, the body temperature returned to normal, and the spirit, diet and sleep were normal. Blood analysis: normal white blood cells, hemoglobin 90g/L; liver function: the indicators were basically normal. Chest X-ray: the lung lesion was absorbed compared with the previous one. At present, the existing treatment plan was maintained. Because the patient’s family lives in Taishan, he comes to Guangzhou once every 2 weeks for follow-up. Discussion 1. Analysis of misconceptions in clinical diagnosis It is well known that neither pulmonary tuberculosis, nor hemolytic anemia, nor drug-related hepatitis are difficult diseases in the relevant specialties today, and the treatment is not complicated and the efficacy is quite certain. But why does a disease that is not clinically complex and difficult go through so many twists and turns? Why did the patient suffer so much financial, physical and psychological loss and stress? Looking back at the diagnosis and treatment process of this patient, who was transferred to several large tertiary hospitals, there are many lessons to remember. Due to the rapid development of medical theory and new technology, the general trend of clinical medicine is becoming more and more specialized and even specialized. This makes the diagnosis and treatment of diseases more specialized and refined, which is generally an improvement. However, specialization also brings many problems. As specialties become more and more subdivided, many physicians’ horizons and ideas become narrower and narrower, almost to the point where their general expertise outside their own specialty is very limited. For example, in this case, hemolytic anemia and pharmacologic liver damage due to anti-TB drugs were accompanied by secondary eosinophilia, and the eosinophilia was accompanied by an abnormally high total white blood cell count. Therefore, the diagnosis in this case, except for pulmonary tuberculosis, should be: hemolytic anemia, drug-related hepatitis, and secondary eosinophilia, and not a leukemia-like reaction (this is an indeterminate diagnosis). Secondary eosinophilia is not uncommon in hematology clinics, and the treatment of choice for both hemolytic anemia and eosinophilia is glucocorticoids. This diagnostic idea is precisely the “monism” principle of interpretation that has long been advocated in clinical thinking, that is, try to use a disease to explain the clinical manifestations and related pathological changes. 2. Methodology of clinical thinking As new theories, new technologies and new methods are emerging, most clinicians are overwhelmed, but tend to neglect the more basic and important basic principles of clinical diagnosis and treatment. Therefore, it is necessary to reiterate the basic principles of clinical diagnosis nowadays: (1) The principle of common sense judgment, based on the basic principle of probability theory. For diseases that appear to be complex or difficult to diagnose, the first thing to consider is the idea of common disease and multiple diseases; (2) the principle of monism. When encountering cases with conflicting and varied clinical appearances, try to use one disease to explain the clinical manifestations and pathological changes. (3) The principle of individualization of treatment. People are not machines, and neither are patients. In the selection of treatment principles, treatment methods, and drug doses, it is important to consider the overall treatment principles, but also the age, gender, occupation, economic status, physical condition, and other factors of the individual with the disease. In an era of proliferation of guidelines, it is particularly important to emphasize individualization of treatment. There is a tendency to push the so-called clinical guidelines to extremes and dogmatize them, and to apply them rigidly. The more time passes, the more obvious and serious the drawbacks of this dogmatization become. Whether it is an infectious disease such as tuberculosis or a hematologic malignancy, it is important to choose different treatment regimens, drugs, and doses because of the physiopathologic differences between individuals with the disease. Tuberculosis of the lung is not a serious aggressive infectious disease, so there is no need for overtreatment. However, due to the influence of various guidelines, some clinicians do not know how to start from the individual, and they just set up books and guidelines without any flexibility, which leads to the common phenomenon of overtreatment. In this case, the patient belonged to the category of relatively weak health, so the treatment should have chosen a relatively small dose of treatment plan, but unfortunately, a large dose was chosen during the inpatient treatment in the chest hospital, which led to serious liver function damage and hemolytic anemia. 3. Clinical thinking must start from the clinic and pay attention to the diagnostic value of clinical symptoms and medical history. Analysis and diagnosis of diseases should start from common sense judgment and avoid falling into the drawback of relying too much on high-grade instruments whenever complex conditions are encountered. The correct diagnostic thinking logic for this case should be: 1. pulmonary tuberculosis (imaging evidence + pathological evidence + pathogenic evidence); 2. anti-TB drugs (isoniazid + rifampin + ethambutol) – hemolysis (jaundice, fever, anemia, drug-induced hepatitis) – -Secondary eosinophilia. 4. Always consider the economic cost and the current situation of the patient. The modern medical model has transitioned from the previous single biomedical model to a multidimensional psychosocial biomedical model, where human subjectivity should be reflected in the whole process of diagnosis and treatment of disease and rehabilitation. 5.In addition to professional knowledge and specialized skills, doctors must also train and improve their logical thinking and judgment ability, cultivate and improve their multidisciplinary and multi-disciplinary knowledge and comprehensive analysis and judgment ability. 6. Pay attention to the training and improvement of one’s basic clinical ability. At present, there is a tendency that when doctors diagnose and treat diseases, especially diseases of high complexity such as hematologic diseases, they often use a certain guideline to guide the clinical thinking and daily work of clinicians, resulting in many doctors only know to mechanically apply such guidelines and theories, while neglecting the training and improvement of their own clinical skills and thinking ability, and lacking the perspective and ability to independently analyze and solve problems. This leads to rigid and paranoid thinking. The philosopher Mencius warned long ago: “It is better to believe in a book than to have no book at all”, which is still worth remembering today.