DIAGNOSTIC ERROR IN THE ERA OF COVID-19: A CASE REPORT

SESSION TITLE: Medical Students/Residents' COVID-19 SESSION TYPE: Med Student/Res Case Report PRESENTED ON: October 18-21, 2020 INTRODUCTION: 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 no-fault 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 CONCLUSIONS: 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 Reference #1: Graber ML, Franklin N, Gordon R Diagnostic Error in Internal Medicine Arch Intern Med [Internet] 2005 Jul 11;165(13):1493–9 Available from: https://doi org/10 1001/archinte 165 13 1493 Reference #2: Yousefzai R, Bhimaraj A Misdiagnosis in the COVID era: When Zebras are Everywhere, Don’t Forget the Horses JACC Case reports Netherlands;2020 Reference #3: Rodriguez-Morales AJ, Cardona-Ospina JA, Gutierrez-Ocampo E, Villamizar-Pena R, Holguin-Rivera Y, Escalera-Antezana JP, et al Clinical, laboratory and imaging features of COVID-19: A systematic review and meta-analysis Travel Med Infect Dis 2020 Mar;101623 DISCLOSURES: No relevant relationships by Brandon Budhram, source=Web Response No relevant relationships by Alexandra Kobza, source=Web Response No relevant relationships by Naufal Mohammed, source=Web Response