Case Presentation: A 76-year-old man with mantle cell lymphoma status post chemotherapy 1 week prior presented to an outside emergency department with generalized weakness. Initial laboratory workup revealed hemoglobin of 8.8 g/dL, platelet count of 3 × 109/L, creatinine 5.55 mg/dL and bicarbonate 7 mmol/L (Table 1). Rectal exam showed brown stool, however fecal occult blood test was positive. He was transferred to a tertiary care facility intensive care unit (ICU) with a diagnosis of gastrointestinal (GI) bleeding. On arrival to the ICU, he was hypotensive with blood pressure of 80/40 mmHg and respiratory rate of 32 breaths per minute. Labs showed severe metabolic acidosis with pH 6.98 and lactate 15.98 mmol/L (Table 2). Given his clinical decline, the decision was made to proceed with intubation. This was complicated by a large episode of emesis that occurred shortly after induction of rapid sequence intubation. Bronchoscopy was performed twice to clear the airway revealing copious amounts of food debris. Central venous and arterial lines were placed to facilitate hemodynamic monitoring and vasopressor administration, as well as CRRT in the setting of undifferentiated shock and renal failure. Additional laboratory workup yielded findings consistent with severe tumor lysis syndrome (TLS) (Table 2). Despite maximal therapies and initiation of CRRT, the patient continued to decline and expired approximately 16 hours following admission.

Discussion: In this case a diagnostic error was thought to be highly likely.The error was thought most related to a number of diagnostic process faults, including: 1. Failure or delay in acting on or following up a test result. There was delayed recognition of severe metabolic acidosis, which was present on arrival to the emergency department. Earlier recognition and evaluation (such as checking a lactate level) may have led to more aggressive work up and stabilization prior to transfer.2. Suboptimal weight or prioritizing of the diagnosis of GI bleed based on positive fecal occult blood test. This diagnostic red herring, combined with anemia and thrombocytopenia, led clinicians to diagnostic anchoring and incomplete workup. 3. Failure or delay in considering the diagnosis of tumor lysis syndrome, which was evident based on laboratory testing and clinical picture of widespread hematologic malignancy with recent chemotherapy.

Conclusions: Harm Resulting from error: The error may have contributed to his death, as there was delayed recognition and treatment of severe metabolic acidosis and tumor lysis syndrome. This delay resulted in rapid decompensation requiring emergent intubation, leading to an aspiration complication. Potential approaches to error prevention: This error was potentially avoidable if the clinicians recognized the laboratory abnormalities and correlated them with the clinical picture of a patient with malignancy who had recently received chemotherapy. The red herring of a low hemoglobin and unreliable positive fecal occult blood test were pursued while critical metabolic acidosis and tumor lysis syndrome went unrecognized. Given the patient’s initially critical condition, it is unclear if early detection and management of tumor lysis syndrome could have delayed or averted death.