The great imitator

The Great Imitator (also the Great Masquerader) is a phrase used for medical conditions that feature nonspecific symptoms and may be confused with a number of other diseases.[1] The term connotes especially difficult differential diagnosis (DDx), especial potential for misdiagnosis, and the protean nature of some diseases. Most great imitators are systemic in nature or have systemic sequelae, and an aspect of nonspecific symptoms is logically almost always involved. In some cases, an assumption that a particular sign or symptom, or a particular pattern of several thereof, is pathognomonic turns out to be false, as the reality is that it is only nearly so.

As recently as the 1950s, syphilis was widely considered by physicians to be "the great imitator", and in the next few decades after that, several other candidates, mainly tuberculosis[2] but occasionally others,[3] were asserted as being "the second great imitator". But because differential diagnosis is inherently subject to occasional difficulty and to false positives and false negatives, the idea that there are only one or two great imitators was more melodrama than objective description. In recent decades, more than a dozen diseases have been recognized in the medical literature as worthy of being considered great imitators, on the common theme of recurring misdiagnoses/missed diagnoses and protean manifestations. Nonetheless, not every DDx caveat (not every mimic) meets the threshold, because it is inherent to DDx generally that there are thousands of caveats (thousands of instances of the theme, "be careful to rule out X before diagnosing Y"); for example, ectopic pregnancy and ovarian neoplasia can mimic each other, as can myocardial infarction and panic attack, but they are not established as great imitators per se (rather, merely DDx considerations). The list of great imitators here relies on references in the medical literature applying that label, or on other references documenting a condition's especially recurrent and poignant reputation for misdiagnoses.

Conditions or diseases sometimes referred to with this nickname thus include the following:

Low blood sugar

Tumors (neoplasms), especially cancerous tumors or any endocrine tumors

Vitamin deficiency

  • Thiamine deficiency (vitamin B₁ deficiency), with focus on subclinical forms and nonsevere clinical forms as well as the severe form called beriberi[9][10]
    • This topic overlaps substantially with the topic of excessive alcohol use, which impairs B₁ metabolism and leads to hepatic encephalopathy. Relatedly, alcohol use disorder has been implicated as a great imitator at least once in the medical literature.[3] But the topic of thiamine deficiency also has been identified as an important component not only of malnutrition in the classic senses of semistarvation or food insecurity but also in the sense of high-calorie malnutrition,[9][10] even in people who do not use alcohol. Hepatic encephalopathy is a wide-ranging topic that includes covert, subclinical, minimal, mild, nonalcoholic, alcoholic, moderate, and severe forms, just as (relatedly) fatty liver disease also has covert, subclinical, minimal, mild, nonalcoholic, alcoholic, moderate, and severe forms. At bottom, it is established that the liver's function and the gut–brain axis affect the brain and thus the mind, although not every correlation is understood.

Rheumatic diseases (most with autoimmune components)

Dysplastic diseases, some with precancerous or rheumatologic aspects

Neurologic disorders

Gut diseases

Endocrine disorders

Thromboembolic events or their mimics

Infectious diseases

Proteinopathies

Abdominal inflammations or their mimics

Mass effect inside the cranium

References

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