Desaturation during the pandemic: Covid or cognitive bias?

The coronavirus pandemic has put an unprecedented strain on our health care system. An urgent need for timely and accurate diagnosis coupled with an inordinate caseload and myriad overlapping signs and symptoms with other differentials is leaving physicians fatigued. This often leads to the use of mental shortcuts - "heuristics" by the strained mind and the inadvertent use of intuitive thought processes rather than the more controlled analytical thinking to cope and speed up the decision-making process. Availability bias - making a recent or vivid patient diagnosis more readily accessible to the mind - and anchoring bias - relying too heavily on a single symptom for deducing diagnosis - are among the most prevalent cognitive biases. Therefore, it is not unexpected that any new cases of acute onset respiratory illness may be mis-diagnosed as coronavirus disease 2019 during the pandemic, significantly impacting the morbidity and mortality of true diagnosis. To reduce the risk of patient harm, it is therefore imperative that medical practitioners be aware of the existence and influence of cognitive bias in clinical decision making and maintain sight of a variety of differential diagnoses to ensure that no adverse condition is overlooked.

A COVID-19 MIMICRY MYSTERY

SESSION TITLE: Signs and Symptoms of Chest Disease Case Report Posters SESSION TYPE: Case Report Posters PRESENTED ON: 10/19/2022 12:45 pm - 01:45 pm INTRODUCTION: Vaping products have been rapidly gaining popularity, with studies showing increasing use, even among school-going children and adolescents. E-cigarette or Vaping Associated Lung Injury (EVALI) is defined as respiratory failure within 90 days of e-cigarette use with pulmonary infiltrates on imaging, in the absence of infectious or alternative causes of respiratory failure.[1] Vitamin E acetate, a thickening agent in THC containing e-cigarettes, is thought to be the main causative agent of EVALI and has been found in the bronchoalveolar lavage samples in almost all cases of EVALI.[2] However, diagnosing EVALI in this era of COVID -19 is a challenge due to striking similarities in clinical symptoms and imaging findings. CASE PRESENTATION: A 32-year-old male with anxiety and polysubstance abuse, presented with headache, cough, low-grade fevers and chills of 1 week. In the ED, he was febrile to 102 F and hypoxic to 89% on room air and was started on 3 liters of oxygen. Labs showed leukocytosis and elevated inflammatory markers. Urine toxicology was positive for THC. Chest X-ray showed bilateral interstitial opacities. CT angio of the chest showed bilateral ground glass opacities. Despite 2 negative PCR tests, suspicion for COVID was high and the patient was initially started on dexamethasone and other supplements, along with antibiotic coverage for a possible bacterial etiology. Despite this, respiratory symptoms and hypoxia continued to worsen. Infectious work up including blood, sputum cultures with AFB staining, urine streptococcus and legionella tested negative. The patient however now revealed the regular use of THC containing vape and procuring the THC oil from a new street vendor. This prompted us to suspect vaping induced chemical pneumonitis. He was restarted on steroid therapy with methylprednisolone and within 1 week, had symptomatic improvement and resolution of hypoxia. The patient was eventually discharged on prednisone taper over 7-10 days. DISCUSSION: Our patient was initially treated for COVID pneumonia despite repeated negative PCR tests, as findings were suggestive of SARS-COV-2 infection. Fortunately, the patient eventually revealed about regular use of THC-oil vapes, making us consider a diagnosis of vaping induced chemical pneumonitis. The mainstay of treatment is steroid therapy and cessation of e-cigarette use. The severity of the pandemic has led to a low threshold for suspecting COVID, causing increased anchoring and availability bias, and potentially under-diagnosing conditions like EVALI which resemble COVID infection.[3] CONCLUSIONS: While it is important to have a low threshold for suspecting COVID-19, considering other mimics of COVID is prudent for providing treatment in an appropriate and timely manner. Detailed inquiry of e-cigarette use, particularly THC-oil containing vapes, duration of use and source of procurement, goes a long way in diagnosing of EVALI. Reference #1: EVALI and the Pulmonary Toxicity of Electronic Cigarettes: A Review Lydia Winnicka, MD and Mangalore Amith Shenoy, MD PMCID: PMC7351931 PMID: 32246394 Reference #2: Clinical presentation, treatment, and short-term outcomes of lung injury associated with e-cigarettes or vaping: a prospective observational cohort study Denitza P Blagev 1, Dixie Harris 2, Angela C Dunn 3, David W Guidry 2, Colin K Grissom 4, Michael J Lanspa 5 PMID: 31711629 DOI: 10.1016/S0140-6736(19)32679-0 Reference #3: EVALI: A Mimicker of COVID-19 Mitchell M. Pitlick, MD,a Daenielle K. Lang, MD,a Anne M. Meehan, MBBCh, PhD,b and Christopher P. McCoy, MDb, PMCID: PMC8006188 PMID: 33817560 DISCLOSURES: No relevant relationships by Kaushik Darbha No relevant relationships by Rashmikant Doshi No relevant relationships by Ishan Sahu No relevant relationships by sara samad

ANTISYNTHETASE SYNDROME PRESENTING AS INTERSTITIAL LUNG DISEASE: A CASE OF ANCHORING BIAS DURING THE COVID-19 PANDEMIC

SESSION TITLE: Dyspne Mysteries SESSION TYPE: Rapid Fire Case Reports PRESENTED ON: 10/18/2022 01:35 pm - 02:35 pm INTRODUCTION: Anti-synthetase (AS) syndrome is characterized by interstitial lung disease (ILD), arthritis, myositis, fever, or Raynaud's phenomenon in the presence of an AS autoantibody (1). At least 70% of patients with AS syndrome develop ILD (2), and it represents the major cause of mortality in these patients with a 10 year survival rate of 73%. In a small cohort study, the anti-PL-12 antibody subtype was found to be strongly associated with ILD (3). CASE PRESENTATION: A 35 year old female with a history of tobacco use disorder presented to the hospital with three months of recurrent subjective fevers, non-productive cough, and dyspnea on exertion. She denied arthralgias, muscle weakness and hemoptysis. She initially presented to her primary care physician with these symptoms and was prescribed amoxicillin for streptococcal pharyngitis. The patient continued to be symptomatic and was treated empirically for COVID-19 pneumonia twice despite two negative COVID-19 tests and without any significant clinical improvement in her respiratory status. On admission, she was febrile, tachycardic, and had a new oxygen requirement with bilateral coarse breath sounds on exam. She had no leukocytosis and her COVID-19 test was negative. CT angiography of the chest showed extensive mixed reticular and airspace opacities with peribronchial predilection and peripheral sparing (figure 1). A bronchial alveolar lavage was notable only for neutrophilia (19%) and eosinophilia (4%). Rheumatological workup revealed elevated rheumatoid factor, positive antinuclear antibody (1:40), weakly positive anti–Sjögren's-syndrome-related antigen A antibody (50 AU/ml), undetectable anti-Jo-1 antibody and positive anti-PL-12 antibody. Pulmonary function testing revealed a TLC of 40% and DLCO of 28%, consistent with a restrictive pattern. Considering the patient's organizing pneumonia, positive antibodies, and findings of "mechanic's hands,” the patient was diagnosed with anti-synthetase syndrome with ILD. She was started on oral prednisone and mycophenolate mofetil. On follow-up, she was noted to have symptomatic improvement and stable hypoxia without clinical signs of disease progression. DISCUSSION: During the coronavirus pandemic, the resemblance of COVID-19 pneumonia to other diseases, in the absence of conscious suspicion for other etiologies, can lead to anchoring and availability bias thereby delaying diagnosis and appropriate treatment. Additionally, anti-synthetase syndrome should be considered in the differential diagnosis of ILD even in the absence of arthritis and myositis, as respiratory symptoms are often the first presenting signs. CONCLUSIONS: Increased responsibility is required of diagnosticians to exercise due diligence and active recognition of COVID availability and anchor bias to avoid missing crucial diagnoses. Reference #1: Cojocaru, Manole, Inimioara Mihaela Cojocaru, and Bogdan Chicos. "New insights into antisynthetase syndrome.” Maedica 11.2 (2016): 130. Reference #2: Marco, Joanna L., and Bridget F. Collins. "Clinical manifestations and treatment of antisynthetase syndrome.” Best Practice & Research Clinical Rheumatology 34.4 (2020): 101503. Reference #3: Kalluri, Meena, et al. "Clinical profile of anti-PL-12 autoantibody: cohort study and review of the literature.” Chest 135.6 (2009): 1550-1556. DISCLOSURES: No relevant relationships by Mario Flores No relevant relationships by David Jackson No relevant relationships by Lisa Saa No relevant relationships by Abu Baker Sheikh

SUBACUTE PULMONARY HISTOPLASMOSIS DISGUISED AS COVID-19 IN A HEALTHY YOUNG MALE

SESSION TITLE: Pathology Identifying Chest Infections Case Report Posters SESSION TYPE: Case Report Posters PRESENTED ON: 10/17/2022 12:15 pm - 01:15 pm INTRODUCTION: Pulmonary histoplasmosis typically affects immunocompromised individuals. Symptomatic infection in immunocompetent patients is rare, however, important risk factors include living in an endemic region and the size of inoculation. We present a case of subacute pulmonary histoplasmosis in a healthy young male and discuss how availability bias during the COVID-19 pandemic may pose challenges in the diagnosis. CASE PRESENTATION: A healthy 30-year-old male presented to our hospital complaining of left flank and bilateral chest pain for one week. The patient returned from Veracruz, Mexico three weeks prior after spending two months there studying to become a chef. While in Mexico, the patient experienced low-grade fevers, night sweats, and pleuritic chest pain for which he was treated with steroids and antibiotics for presumed COVID-19 infection despite negative testing. Treatment provided the patient temporary relief, however, some of his symptoms returned prompting him to present to the emergency department. Upon presentation, the patient was afebrile and had a normal resting pulse oximetry. CT angiogram of the chest demonstrated three lung nodules and prominent mediastinal lymphadenopathy. A complete infectious and rheumatologic workup was performed. BAL, transbronchial biopsies and EBUS-TBNA were performed. Lung biopsy showed reactive pneumocytes, focal intra-alveolar fibrinous material, congestion, and hemorrhage. Lymph node cytology revealed an aggregate of necrotizing and nonnecrotizing granulomas and GMS stain was positive for yeast. Fungitell and Histoplasma antibodies returned positive. The patient was discharged on Itraconazole and followed up with infectious disease specialists two months later in stable condition. DISCUSSION: Patients with subacute pulmonary histoplasmosis and viral pneumonia may present with similar clinical and radiological findings making the diagnosis arduous. In addition, the prevalence of COVID-19 pneumonia makes clinicians susceptible to using availability bias and further obscuring diagnosis. Some clues that help differentiate subacute pulmonary histoplasmosis include a longer duration of symptoms, pulmonary nodules, and mediastinal and hilar adenopathy. CONCLUSIONS: While pulmonary histoplasmosis is an uncommon finding in immunocompetent patients, suspicion should be raised in patients from endemic regions. Despite the COVID-19 pandemic, clinicians should avoid anchoring biases and keep differential diagnoses in mind. Reference #1: Azar MM, Hage CA. Clinical Perspectives in the Diagnosis and Management of Histoplasmosis. Clin Chest Med. 2017;38(3):403-415. doi:10.1016/j.ccm.2017.04.004 Reference #2: Staffolani S, Buonfrate D, Angheben A, et al. Acute histoplasmosis in immunocompetent travelers: a systematic review of literature. BMC Infect Dis. 2018;18(1):673. Published 2018 Dec 18. doi:10.1186/s12879-018-3476-z DISCLOSURES: No relevant relationships by Steven Douedi No relevant relationships by Justin Ilagan No relevant relationships by TAIMOOR KHAN No relevant relationships by Romany Nightingale No relevant relationships by Mihir Odak No relevant relationships by Noor Salam No relevant relationships by Kameron Tavakolian

Availability Bias and the COVID-19 Pandemic: A Case Study of Legionella Pneumonia.

Cognitive biases, such as the availability heuristic or availability bias, can inadvertently affect patient outcomes. These biases may be magnified during times of heightened awareness of a particular disease. Failure to identify cognitive biases when managing patients during the coronavirus disease 2019 (COVID-19) pandemic can delay the institution of the right treatment option and result in poor health outcomes. We present a case of delayed diagnosis of Legionella pneumonia due to COVID-19-related availability bias. We discuss some methods to mitigate the effects of this bias and the importance of challenging trainees to recognize these pitfalls in medical training.

MISDIAGNOSIS OF KIKUCHI-FUJIMOTO DISEASE: THE IMPORTANCE OF TIMELY HISTOPATHOLOGY IN LYMPHADENITIS

Background: Febrile lymphadenopathy not responding to first line antibiotics in a patient hailing from or with a history of travel to tuberculosis endemic countries is often primarily diagnosed as extra-pulmonary tuberculosis. However, histiocytic necrotizing lymphadenitis or Kikuchi-Fujimoto Disease(KFD) presents with similar clinical features. Etiological theories of KFD include viral agents, autoimmunity, and physicochemical factors such as leaking implants. Although KFD has classically been described in young Asian females, recent studies show men and women can be equally affected, with cases increasingly being reported from the USA and Europe as well. Availability bias amongst physicians can lead to misdiagnoses, especially in patients from tuberculosis endemic countries. Objectives: To describe a case of misdiagnosis of KFD in an adolescent. Design/Method: Case report. Results: A 16-year-old male from a tuberculosis endemic country, with a history of asthma, eczema and excision of omental infarct, presented with sub-occipital lymphadenopathy which resolved with antibiotics. Six months later, he complained of tender left cervical lymphadenopathy, associated with fever and fatigue, which lasted for a month. Two courses of antibiotics failed to decrease symptoms. Based on his clinical history, he was started on empirical anti-tubercular medications despite negative tests for tuberculosis. However, his symptoms began to worsen after three weeks of this treatment, and he developed high evening rise of temperature associated with chills, night sweats, frontal headache, pedal edema and generalized pruritic maculopapular rash. Laboratory workups revealed leukopenia (WBC:3830/μL);elevated Erythrocyte sedimentation rate (29 mm/h), C-reactive protein (68.6 mg/dL), Aspartate Aminotransferase(95 U/L) and Alanine Aminotransferase(61 U/L). Rapid antigen test for SARS-CoV2 was negative, and no appreciable levels of SARS-CoV-2 IgG antibodies were detected. Investigations for Tuberculosis, EBV, CMV, Dengue, Malaria, Typhoid, Leptospirosis and Scrub typhus were all negative. Chest X-ray and abdomen ultrasound scan were normal. Histopathological analysis of the excised cervical lymph nodes demonstrated crescentic histiocytes and karyorrhexis in a background of coagulative necrosis. Neutrophils, granulomas and acid-fast bacilli were absent. Immunohistochemistry was positive for CD3, CD20, CD68;and negative for CD15, CD30 and PAX-5. A diagnosis of KFD was made, and patient was given supportive treatment only. His symptoms rapidly resolved within 48 hours, with complete resolution by three months. Conclusion: It is important to raise awareness of KFD, a benign and self-limiting condition with good prognosis, which has many clinical symptoms mimicking grave conditions like extra-pulmonary tuberculosis, SLE and lymphomas. Timely histopathological analysis can help avoid anxiety surrounding a misdiagnosis and adverse reactions due to unnecessary toxic treatments.

A case of e-cigarette/vapingassociated lung injury in the era of COVID-19

INTRODUCTION: E-cigarette or vaping product use associated lung injury (EVALI) is a recently described acute or subacute respiratory illness due to inhalation of toxic e-cigarette ingredients. Symptoms can include shortness of breath, cough, fever, chills, and gastrointestinal symptoms. It is a diagnosis of exclusion made in patients with history of vaping. DESCRIPTION: A 25-year-old male with history of untreated hypertension, childhood asthma, and regular vaping presented to the emergency department with 5 days of dyspnea, fever, nausea, vomiting, and diarrhea. He had a fever to 101.2 F and hypoxia requiring 2 L/min supplemental oxygen by nasal cannula. He had leukocytosis to 21/mm3. Chest CT revealed multifocal ground glass consolidations. His presentation was highly concerning for COVID-19, and he was designated a person under investigation (PUI) with agreement by the infectious disease consultation. PCR test for COVID-19 was negative. He was started on ceftriaxone and azithromycin for empiric treatment of community acquired pneumonia. However, three days later his oxygen requirement increased to high flow nasal cannula. HIV, urine legionella and streptococcal antigens, respiratory viral panel, and blood cultures were negative. COVID-19 testing was repeated twice due to suspicion of false negative and was negative, but he was started on dexamethasone per COVID-19 protocols as he continued to be a PUI. Additionally, he was encouraged to self-prone and use incentive spirometry. Hypoxia initially started to improve, but worsened again along with a recurrent fever, prompting initiation of a second course of antibiotics. Ultimately, it was concluded that there was no active infectious etiology for his hypoxic respiratory failure and he likely has EVALI. He was weaned off of oxygen after 2 weeks of hospitalization and was discharged with follow-up. DISCUSSION: This case demonstrates the susceptibility of physicians to the availability heuristic when developing a differential diagnosis during the COVID-19 pandemic. Particularly, the presentation of EVALI is remarkably similar to that of COVID-19. One of the few distinguishing features is leukocytosis in EVALI, whereas COVID-19 typically presents with leukopenia. It is important to maintain a broad differential including EVALI and assess patients for history of vaping.