Case Presentation:

A 51–year–old uninsured African American female with no past medical history presented to clinic with bilateral leg swelling, generalized weakness and unintentional weight loss. Her exam was notable for temporal wasting, conjunctival pallor, diffuse lymphadenopathy, splenomegaly and 3 + pitting edema to her knees. She was found to have a hemoglobin of 6.6 g/dL, serum iron 12 mcg/dL, transferrin 9 mg/dL, albumin 1.8 and 4 + proteinuria. A CT scan of her chest revealed a large pericardial effusion and loculated right pleural effusion. She was admitted for further work–up, with concern for malignancy, primarily lymphoma, followed by infectious etiologies. Her inpatient course was notable for multiple transitions of care between the cardiac care unit and floor teams as a result of her recurrent large pericardial effusion causing cardiac tamponade and requiring pericardial window. She was followed by hematology and suspicion for lymphoma remained high, driving her work–up including lymph node biopsy, bone marrow biopsy, flow cytometry and cytology of blood, pleural and pericaridial fluid. Infection was ruled out. The renal consult team concluded that the patient’s nephrotic range proteinuria was likely paraneoplastic, recommending identification of the underlying malignancy. Only after the above work–up was inconclusive was the decision made to send rheumatologic studies. ANA was positive at 1:640 and anti–dsDNA antibody was also positive. Notably, on review of the pericardial biopsies, rheumatology clarified that the “LE” cell reported was a lupus erythematosus cell. The diagnosis of systemic lupus erythematosus was made and the patient was started on prednisone and hydroxychloroquine. She was discharged 28 days after admission to a sub–acute rehabilitation facility.

Discussion:

The initial evaluation of a woman with many concerning symptoms was limited due to her lack of insurance and focused mainly on malignancy and infection. However, once she was hospitalized this persisted. Diagnostic momentum occurs when physicians accept previous physicians’ leading diagnosis without reviewing the case independently and developing their own differentials. This patient’s initial outpatient workup was limited by her lack of insurance, but diagnostic momentum was sustained because of the multiple inpatient transitions of care between the CCU and different medicine teams. As transitions of care from outpatient to inpatient and within hospitalizations increase, it is essential to minimize diagnostic momentum. Similarly, anchoring errors occur when clinicians use only partial clinical information to guide diagnosis and fail to weigh the entire clinical picture. This occurred throughout this case even as more information became available that in retrospect made lupus a leading diagnosis.

Conclusions:

This case highlights the risks of diagnostic momentum in this age of increasing transitions of care.