General practitioners from many European countries, can legally use diverse systems of paraclinic investigations (ultrasound, EKG,spirometry) which furnish useful information, which can be used along with history of present illness and physical exam to increase the precision and accuracy off a diagnosis.

This proceeding is useful for the physician and is in the patients and the medical system`s best interest because it greatly reduces cost.

However putting aside the unavoidable difficulties (the need for special imaging room, and the small chance of finding in Europe a way to certify competency in thermography), I will raise this question: what is the place for clinical thermography in family practice?

I will present a few cases from a family medicine medical practice, mentioning that there was not a thermographic diagnostic made, but rather a corroboration of clinical data with thermographic images, hoping this would lead to the formulation of a beginning of an answer.

All the diagnostics in this paper have been confirmed by other means for by inpatient admission.

Acute appendicitis

Appendicitis is the first cause of acute abdomen in the western world. Approximately 30% of patients present with atypical symptoms, which can delay the diagnosis. Thus, in the US, the high mortality of 20% in elderly over 70 years old is caused by the diagnostic and therapeutic delay. Perforation rate is higher among patients younger than 18 years and patients older than 50 years, possibly because of delays in diagnosis.

In classic medicine it is well known that a 0.5 degree rise in the right lower quadrant temperature is an important sign in the diagnosis of acute appendicitis, even in the modern days of ultrasound, CT and MRI. Nowadays, using the hand to appreciate a rise in the local temperature is no longer needed as thermography can easily and accurately measure the local temperature gradient. While thermography cannot establish a diagnosis of acute appendicitis, it supports the clinical suspicion, so that the patient benefits from the aforementioned investigations for a quick diagnosis. Presented here is the thermographic image of a retrocecal appendicitis difficult to diagnose clinically. (Img 1)

Carpal tunnel syndrome

Especially after it was acknowledged that PC keyboard can lead to carpal tunnel syndrome, the incidence of these diagnoses has increased in geometric progression. At the same time, even with proper treatment many patients have residual symptomatology which is difficult to evaluate.

As you can see from image (Img 2) the thermography can offer interesting informations for the family doctor both in the stage of making this diagnosis, but also to follow this condition after the treatment.

Herpes zoster(shingles)

In some cases before the actual skin eruption, herpes zoster raises serious differential diagnosis issues because of the intense pain in the affected territory. An early diagnosis in the pre-eruptive state is especially useful in ophthalmic herpes zoster, before the cornea is affected.

Male breast cancer

Breat cancer in men is more severe than in women. Since it is infrequent, the diagnosis is not commonly considered by either patients or physicians since the age of onset is usually past 60 when most men have gynecomastia, which can mask a breast mass/tumor in the initial stages.

I will be presenting the case of a man who presented to my office for a second opinion to be evaluated for bilateral mastodynia on superimposed gynecomastia. The symptoms were initially attributed to the treatment with spironolactone, which the patient had been taking for several years. The clinical evaluation revealed nothing else than gynecomastia

Thermographic exam showed (Img 5):

1.      Hyperthermic nipple (temperature gradient + 1.8 Celsius)

2.      Hyperthermic areola (temperature gradient + 2.6 Celsius)

3.      Overall right breast temperature was elevated

Finally patient was diagnosed with ductal cancer.

Deep vein thrombosis

Incidence of Deep venous thrombosis(DVT) is 1000/100 000persons annually in the general population over 60 years of age. Venous thromboembolism death in the US is estimated at 300 000 annually

The clinical diagnosis of deep venous thrombosis has been shown to be extremely unreliable.

Our patients presenting with typical clinical symptoms of deep vein thrombosis were evaluated according to the following algorithm (Img 6):

Step1 : Wells score 0-1 : Watchfull waiting

Score higher than 1 –

Step2 : thermography

Negative :  watchfull waiting

Positive : a marked and asymmetric rise in calf temperature with loss of normal temperature gradient down the affected limb

Step 3 : exclusion through clinical examination of alternate diagnoses : cellulitis, varicose veins, superficial thrombophlebitis, ruptured Baker cyst, erisipella, muscle tear, arthritis. Once these diagnoses are excluded, the clinical suspicion for DVT is high and patients are referred to venous ultrasound

CONCLUSIONS

The presentation of these cases had the purpose of lunching the discussion about the utility of thermography in general practice. This is frequently used in Ireland, Israel, Romania and other European countries.

I do believe that we must share our experiences and an “expert panel” should determine what the place of this investigation modality is in the diagnostic protocol of a family physician.