SESSION TITLE: Medical Student/Resident Chest Infections Posters
SESSION TYPE: Med Student/Res Case Rep Postr
PRESENTED ON: October 18-21, 2020
INTRODUCTION: Anchoring bias is defined as relying too much on the initial information provided, when making our own impression. While anchoring affects our everyday lives, in times of stress and anxiety, it affects us even more. The following case illustrates, how the COVID-19 pandemic may have further contributed to this phenomenon in medical decision making.
CASE PRESENTATION: A 17-year-old girl presented to the emergency department during the COVID-19 pandemic with a five-day history of decreased appetite, vomiting, diarrhea, fever, dry cough, and shortness of breath. She denied practicing social distancing and admitted to smoking marijuana daily as well as occasional vaping. The day before presentation, she was tested for COVID-19 in a drive-up clinic, the result of which was pending. Vital signs were significant for a HR of 140 bpm, RR of 30/min, and SpO2 of 82% on ambient air. Labs showed a WBC count of 18 K/uL, CRP of 405 mg/L, LDH of 539 IU/L, ferritin of 270 ng/mL, and D-dimer of 2.5 ug/mL. Rapid test for SARS-CoV-2 was negative. CT chest with IV contrast did not show pulmonary embolism but was notable for bilateral groundglass opacities and bibasilar consolidation. Clinical suspicion for COVID-19 remained high, especially with these typical radiographic findings. Because of her history of vomiting with possible aspiration, treatment with ceftriaxone was initiated. On hospital day 2, she had worsening hypoxia, requiring 15 L of oxygen via non-rebreather. Inflammatory markers had risen significantly. She was transferred to the intensive care unit and covered broadly for bacterial pneumonia with vancomycin, levofloxacin, and metronidazole. Prednisone was initiated due to concern for vaping-induced lung injury. On hospital day 3, mycoplasma IgM antibody test returned positive. The SARS-CoV-2 test collected prior to admission as well as a third test, 72 hours after admission, were negative. Over the next days, oxygen requirements decreased, and chest x-ray showed improvement of infiltrates. She completed a 7-day course of levofloxacin and was discharged on a slow steroid taper.
DISCUSSION: During the COVID-19 pandemic, the combination of shortness of breath, cough, fever, elevated inflammatory markers and CT findings of bilateral groundglass opacities and consolidations raise high suspicion for SARS-CoV-2. However, anchoring on this diagnosis, may lead to an inappropriate exclusion of alternate diagnoses. This atypical presentation of mycoplasma pneumonia in a 17-year-old, possibly with increased inflammatory response due to vaping, demonstrates the importance of a complete workup for other infectious and non-infectious causes, even if COVID-19 is considered a possible explanation.
CONCLUSIONS: Anchoring bias needs to be considered especially during the COVID-19 pandemic. Even in patients with a high pretest probability for SARS-CoV-2 infection, alternate diagnoses must remain on the differential.
Reference #1: Tversky and D.Kahneman.1974. Judgment under uncertainty: Heuristics and biases. Science, 185, 1124–1130.
DISCLOSURES: No relevant relationships by Mouhanned Eliliwi, source=Web Response
No relevant relationships by Jennifer Meyfeldt, source=Web Response
My spouse/partner as a Employee relationship with Merck Please note: >$100000 Added 05/26/2020 by Niraj Patel, source=Web Response, value=Salary