key: cord-0926841-vtapdn06
authors: Budhram, Brandon; Kobza, Alexandra; Mohammed, Naufal
title: DIAGNOSTIC ERROR IN THE ERA OF COVID-19: A CASE REPORT
date: 2020-10-31
journal: Chest
DOI: 10.1016/j.chest.2020.08.2125
sha: 7f57a69e35fe4b9a8f479037d1e63bd06bc6a449
doc_id: 926841
cord_uid: vtapdn06

nan

BRANDON BUDHRAM ALEXANDRA KOBZA AND NAUFAL MOHAMMED

The rapid spread of the Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) virus has resulted in the rapid dissemination of COVID-19-related literature, much of which is conflicting and quickly evolving. As such, medical professionals are becoming increasingly prone to diagnostic error-fueled by a combination of cognitive, system-related, and nofault errors-that may lead to delay in diagnosis and subsequent management, as in our patient. Given that the existing literature on diagnostic errors related to COVID-19 is limited only to case reports, our patient example may shed light on an underappreciated concern during this pandemic.

CASE PRESENTATION: An otherwise healthy 40-year-old female was admitted to the General Internal Medicine service following a 10-day history of productive cough, fatigue, chills and documented fevers. Her laboratory investigations, chest x-ray, and computed tomography of the chest were highly suspicious of COVID-19, despite three separate negative PCRs. She had a bronchoscopy prior to discharge and was found to have pneumocystis jirovecii. She was re-admitted and found to be HIV-positive with a viral load of 679,110 and a CD4 count of 10. A new, focused review of systems demonstrated 6-months of constitutional symptoms, active HSV-2 infection, and a sizeable Kaposi's sarcoma lesion.

DISCUSSION: Our patient demonstrated the five most common manifestations, four most common laboratory investigation, and the most common imaging findings associated with COVID-19. With these characteristic features, it remained the leading differential diagnosis until bronchoscopy despite three negative PCRs. The unfortunate series of events that impeded time to diagnosis illustrates multiple cognitive errors: overestimating the importance of investigations, faulty history-taking and physical examination, and most importantly, premature diagnostic closure. Following case resolution, the patient's healthcare team performed a "cognitive autopsy" and agreed that the delay in diagnosis was fueled by premature closure secondary to COVID-19.

The COVID-19 pandemic has transformed the landscape of medicine, likely for years to come. Clinicians will be expected to adapt by incorporating COVID-19 into their existing illness scripts for common presentations, including fever, cough, and shortness of breath, among others. Part of this adjustment lies in a physician's ability to recognize COVID-19 as one, but not the only, diagnostic explanation. In light of this, our case report employs high-quality evidence to clearly outline a path leading toward misdiagnosis and highlights the predilection for diagnostic errors inherent to the COVID-19 pandemic. We urge clinicians to critically review patients periodically during the diagnostic workup of COVID-19, particularly in the absence of a confirmatory result.

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Misdiagnosis in the COVID era: When Zebras are Everywhere, Don't Forget the Horses

Clinical, laboratory and imaging features of COVID-19: A systematic review and meta-analysis