CLINICAL COMMUNICATION TO THE EDITOR

Occam’s Razor and the Diagnosis CD20 positive and cyclin D1 positive. The Ki-67 index
of Mantle Cell Lymphoma was >90%. Cytogenetics were complex, including a p17
deletion, but without the typical translocation seen in mantle
To the Editor: cell lymphoma.

Occam’s razor is a principle of parsimony commonly

applied to diagnostic medicine in minimizing assumptions
to arrive at an explanation. We present a case of what
appeared to be a simple case of diverticulitis where a patient
was diagnosed concomitantly with lymphoma. In this
instance, further work-up was triggered by an abnormality
in a complete blood cell count differential, an easily missed
element following the establishment of a unifying diagnosis.
DISCUSSION
Over the ages, multiple philosophies in diagnostic medicine
have surfaced, including Saint’s Triad and Hickam’s
dictum. These both advocate for multiple separate diagnoses
to arrive at an explanation vs Occam’s razor advocating for
diagnosis solidarity.1 As physicians, we often recognize a

CASE REPORT
An 82-year-old gentleman presented with mid-epigastric
pain over 3 months associated with nausea. His pain
improved with eating, although he had been experiencing
subtle weight loss over the past month. He denied any fe-
vers. However, he did experience a single loose bowel
movement. He carried no family history of blood dyscrasias
or lymphomas, but did carry a family history of breast
cancer. A complete blood cell count was ordered, which
revealed a white blood cell count of 26,300/mm3. Given his
abdominal pain and leukocytosis, a computed tomography
scan of the abdomen was obtained, revealing inflammatory
changes surrounding a colonic outpouching consistent with
acute diverticulitis. He was started on antibiotics and
his symptoms improved. A subsequent differential of his
complete blood cell count returned showing 39% poly-
morphonuclear leukocytes, 11% lymphocytes, 1% mono-
cytes, and 48% pathologic cells (Figure). A complete blood
cell count 3 months prior showed a normal white blood cell
count with a normal differential. Given the abnormal
peripheral smear, a bone marrow biopsy was obtained
revealing changes consistent with mantle cell lymphoma,
blastoid variant, involving 40% of cells. There was normal
maturation of the myeloid and erythroid series with
megakaryocytes. The cells in the bone marrow were

Funding: None.
Conflict of Interest: The authors have no conflicts of interest to
disclose.
Authorship: All authors had access to the data and a role in writing the
manuscript.
Requests for reprints should be addressed to Justin K. Lui, MD,
Department of Medicine, University of Massachusetts Medical School, Figure Peripheral smears detailing mono-
55 Lake Avenue North, Worcester, MA 01655. nuclear cells and very prominent nucleoli.
E-mail address: justin.lui@umassmemorial.org

0002-9343/$ -see front matter Ó 2015 Elsevier Inc. All rights reserved.
e26 The American Journal of Medicine, Vol 128, No 12, December 2015

pattern and attempt to coalesce a patient’s presenting CONCLUSION

symptoms into a unifying diagnosis. Although a diagnosis
may seem clear, it is necessary to perform a thorough work-
up to exclude less common or concomitant etiologies.
Ultimately, this patient was diagnosed with a rare variant of
mantle cell lymphoma. He had a seemingly straightforward
diagnosis of diverticulitis based on history, physical exam-
ination, and imaging. In agreement with Occam’s razor,
diagnostic work-up would have ceased upon arrival at the
initial diagnosis. Furthermore, in retrospect, the patient
possessed few risk factors for lymphoma, including only age
and sex, but no family history of hematologic malignancies.
He did, however, present with subtle weight loss that would
not be typical of diverticulitis alone. With modern medi-
cine’s increasing proclivity for cost cutting and waste
reduction, the “shotgun” approach to diagnostic testing is no
longer practical or appropriate. A minimal number of tar-
geted tests arrived at a clinically sound diagnosis of diver-
ticulitis. However, had the work-up stopped, the insidious
diagnosis would have been missed. Simplicity and thrift
should not preclude thoroughness. This case illustrates the
importance of a comprehensive diagnostic work-up when
the possibilities of additional etiologies still exist. In this
case, a differential of the elevated white blood cell count
was reasonable and should constitute a crucial step in the
overall diagnostic decision tree whenever evaluating for
leukocytosis.2
In the modern era of medicine, diagnostic parsimony is
sought often, coinciding with the rationalization of health
care resources. A single diagnosis should not be the be-all
and end-all, especially with the current state of patients
living longer and often carrying with them a multitude of
illnesses that come with age.
Justin K. Lui, MDa
William Gillespie, MDa
Robert Gaudet, MDa,b
Doreen B. Brettler, MDa,b
a
Department of Medicine
University of Massachusetts Medical School
Worcester
b
Division of Hematology and Oncology
University of Massachusetts Medical School
Worcester
http://dx.doi.org/10.1016/j.amjmed.2015.06.050
References
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Clinical problem-solving. Occam’s razor versus Saint’s Triad. N Engl J
Med. 2004;350(6):599-603.
2. George TI. Malignant or benign leukocytosis. Hematology Am Soc
Hematol Educ Program. 2012;2012:475-484.