key: cord-0965948-6653xq9t authors: Karn, Michele N.; Johnson, Nicholas P.; Yaeger, Susan K.; Fugok, Kimberly L. title: A teenager with fever, chest pain, and respiratory distress during the coronavirus disease 2019 pandemic: a lesson on anchoring bias date: 2020-09-26 journal: J Am Coll Emerg Physicians Open DOI: 10.1002/emp2.12261 sha: ce5f6edd287ba0fd0a9b26419ae726a118260bff doc_id: 965948 cord_uid: 6653xq9t Symptoms of coronavirus disease 2019 overlap with other important illnesses affecting young adults. We report a case of a 17‐year old male presenting to the emergency department in the midst of a pandemic with symptoms of coronavirus disease 2019. He had fever, dyspnea, chest pain, and myalgias, with bilateral infiltrates on chest radiograph, and developed septic shock secondary to infectious thromboembolic events. However, his blood cultures grew group G streptococcus secondary to his oropharyngeal infection, and he experienced an infectious thrombus in the internal jugular vein, consistent with the rare but well‐described Lemierre's syndrome. This case report calls attention to the importance of maintaining differential diagnoses and thereby minimizing the biases and assumptions that come with clinical care during a pandemic. A previously healthy 17-year-old male presented to the emergency department (ED) with a 7-day history of worsening symptoms, including left-sided sore throat, chills, diarrhea, vomiting, diffuse body aches, right-sided chest pain, and persistent fever. Throughout the past week, he had several outpatient and ED evaluations, including negative testing for strep pharyngitis, influenza, mononucleosis, and Epstein-Barr virus. He also had 2 nasal swab specimens collected for severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) virus testing. Both were polymerase chain reaction tests, and both were eventually Lemierre's syndrome is a rare disease that is estimated to have a worldwide incidence of 1/1,000,000. 1 Typical treatment for Lemierre's syndrome involves intravenous antibiotics to treat the underlying pathogens. The use of anticoagulation medication, such as low-molecular weight heparin, is considered controversial, as limited research has been done with regard to its effectiveness in Lemierre's syndrome. 4, 6 This patient was evaluated in the midst of a COVID-19 pandemic in a geographic area that was greatly affected by the high prevalence of SARS-CoV-2. Despite a sore throat, he was triaged into an ED pod for cohorted patients with suspected COVID-19. This initial decision could potentially have led to further cognitive errors on the part of the treatment team. Putting too much weight on this initial presentation of fever in a pandemic would have been consistent with "anchoring bias" in which initial facts distort the clinician's ability to take in further information objectively. 7 It has been well established that clinicians who succumb to anchoring effects are more likely to make diagnostic errors. [8] [9] [10] [11] Despite the patient's initial findings, some of which This case report summarized the presentation and treatment of a 17- year-old male who was ultimately diagnosed with Lemierre's syndrome days after being treated as a presumed COVID-19 case. Although he was successfully treated for Lemierre's syndrome, this case illustrates the importance of exploring various diagnoses even when symptoms are consistent with the disease of a current global pandemic. We acknowledge Marna Rayl Greenberg for formatting and editing. The article publishing fees for this manuscript were generously provided by a nonprofit community foundation, the Dorothy Rider Pool Health Care Trust Awards for Clinical Transformational Excellence. The authors have no additional outside support information, conflicts, or financial interest to disclose. Lemierre syndrome Lemierre's syndrome Lemierre's syndrome: more than a historical curiosa Lemierre's syndrome: a systematic review The long shadow of Lemierre's syndrome Lemierre's syndrome: current perspectives on diagnosis and management Cognitive biases associated with medical decisions: a systematic review Doctors and patients' susceptibility to framing bias: a randomized trial The relationship between obstetricians' cognitive and affective traits and their patients' delivery outcomes Why do primary care physicians in the United States and France order prostate-specific antigen tests for asymptomatic patients Decision-making and safety in anesthesiology The evolution of group a streptococcus pharyngitis testing False negative tests for SARS-COV-2 infection-challenges and implications A teenager with fever, chest pain, and respiratory distress during the coronavirus disease 2019 pandemic: a lesson on anchoring bias