A Case Report of Fever in an Intravenous Drug User: A Reminder of Cognitive Bias
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MEDICINE
A Case Report of Fever in an Intravenous Drug User: A Reminder of Cognitive Bias Jaclyn Rivington 1
&
Patrick A. Twohig 1
&
Jennifer Hanrahan 2
Accepted: 21 September 2020 # Springer Nature Switzerland AG 2020
Abstract The practice of medicine requires a widespread knowledge base. Both experienced and newly trained physicians develop heuristics to help sort through the extensive list of diagnoses and the symptoms, signs, and sequelae associated with each one. This case highlights the importance of taking a diagnostic time out when a patient is not improving clinically despite aggressive treatment. Fever is a common symptom encountered in clinical practice, and our case highlights a rare etiology of fever in a young male. This report presents a young male with fever, back pain, and a history of intravenous drug use. It was initially labeled as a straight-forward case of an epidural abscess; however, after a long hospital course, it evolved into a diagnostic dilemma. The patient was ultimately diagnosed with ALK-anaplastic large cell lymphoma, an extremely rare and aggressive malignancy. Diagnosis may have been delayed due to cognitive bias and anchoring on an initial diagnosis suspected to be from an infectious process. It is essential for all practitioners to be mindful of their heuristics in clinical practice and susceptibility to cognitive biases. This can avoid delays in diagnosis and ensure timely treatment of potentially aggressive malignancies. Keywords Cognitive bias . Intravenous drug user . Lymphoma . Anchoring . Case report
Introduction The study of medicine requires recall and understanding of an abundance of information. From the beginning of medical school, our minds learn to create heuristics or diagnostic shortcuts to mitigate the overload of information. “Barking cough” reminds us of croup, and a pill-rolling tremor with shuffling gait, we reflex to Parkinson’s disease. On the wards, a patient with fever, back pain, and intravenous drug use (IDU) often prompts a workup for vertebral osteomyelitis/epidural abscess. However, when comorbid or undiagnosed diseases co-exist, the diagnostic picture is clouded. Determining when Electronic supplementary material The online version of this article (https://doi.org/10.1007/s42399-020-00540-5) contains supplementary material, which is available to authorized users. This article is part of the Topical Collection on Medicine * Jaclyn Rivington [email protected] 1
Department of Medicine, Case Western Reserve University, MetroHealth Hospital, 2500 MetroHealth Drive, Cleveland, OH 44109, USA
2
Department of Medicine, University of Toledo, Toledo, OH, USA
a fever is not from an infectious source and initiating workup for alternative causes is challenging (Fig. 1). When reading through the following case, at what point would you take a step back, question the management, or take a diagnostic time out?
Case Presentation A 33-year-old male with recent IDU presented with severe back pain and lower extremity (LE) weakness after a 15 ft. fall
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