Spot the Diagnosis! The case of the Jovial Man

In Arts PRN, Medical Concepts by Tetyana Maniuk2 Comments

Drunken Silenus by Ribera (click to enlarge the image)

As part of the Arts PRN series, we will intermittently be featuring pieces of historic art that hint at an underlying medical condition. They say a picture is worth 1000 words… can you Spot the Diagnosis after examining only a painting? Read on to learn not only about the art, but about these fascinating medical conditions. Who knows, maybe they’ll help you make a diagnosis some day (or at least help you out on Jeopardy)! After you read, consider submitting your own art to the Arts PRN Project.

Using hints and cues from this painting, Drunken Silenus by Ribera, can you figure out what ails our Jovial Man?


What signs do you see that point to a potential diagnosis?

This man is showing stigmata of liver disease likely secondary to excessive alcohol intake. It is not a surprise to learn that Silenus (the man featured in this painting) is the designated companion of the Greek god of wine Dionysus according to mythology. Perhaps Ribera asked the town wine connoisseur to pose for this painting?

Aside from jaundice, here are some signs that are seen on the painting:

What are some other stigmata of liver disease?

  • scleral icterus
  • jaundice
  • frontal balding
  • temporal wasting
  • parotid gland enlargement
  • spider angioma
  • gynecomastia
  • caput medusae
  • ascites
  • half and half nails
  • terry’s nails
  • Dupuytren’s contracture
  • asterixis
  • testicular atrophy
  • pitting edema

What are some signs and symptoms of liver disease?

Symptoms can include nausea and vomiting, weight loss, fevers, generalized abdominal pain and anorexia. Signs can include: tender hepatomegaly (in ~85% of cases) and stigmata of liver disease.

What is the progression of liver disease in chronic alcohol use?

90% of chronic alcohol users will develop steatosis, which leads to fibrosis and finally cirrhosis.

What are some acute complications of liver cirrhosis?

Liver cirrhosis is the 5th leading cause of death in the United States, with chronic alcohol use being the most common cause of cirrhosis.1

  • Esophageal varices
  • Ascites
  • Acute hyponatremia
  • Hepatocellular carcinoma
  • Hepatic encephalopathy
  • Spontaneous Bacterial Peritonitis
  • Liver failure
  • Hepatorenal syndrome
  • Cholelithiasis
  • Pericardial effusion
  • Hyposplenism

How do you manage acute liver cirrhosis complications?

For information about liver cirrhosis and its acute management, listen to (or read) this excellent CrackCast! [bg_faq_end]

More Spot the Diagnosis! posts

The Case of the Ugly Duchess

The Case of the Pale Woman

The Case of the Recluse

For more information on Arts PRN, click here.


Starr S, Raines D. Cirrhosis: diagnosis, management, and prevention. Am Fam Physician. 2011;84(12):1353-1359. [PubMed]

Tetyana Maniuk

Tetyana is a PGY1 EM resident at uOttawa with a passion for the arts. She is the Editor of CanadiEM's Arts PRN Section.