Case Presentation: An 82-year-old woman with hypertension, diabetes, and a renal transplant recipient for diabetic nephropathy was admitted with three days of chills, cough, dyspnea, and increased urinary frequency. Her urinalysis was positive for pyuria and hematuria, and she was diagnosed with cystitis. Chest radiograph on admission was read as clear by radiology. She was placed on empiric meropenem while awaiting results of blood and urine cultures. On hospital day six, the patient developed fevers, leukocytosis, and a new oxygen requirement of 1-2L/min by nasal canula. Physical exam revealed left lower lobe rales that was attributed to atelectasis by the primary team. A subsequent CT scan of the lungs demonstrated multifocal airspace opacities and small bilateral effusions. The infectious disease consultant recommended broadening antimicrobial coverage to ceftazidime-avibactam, metronidazole, anidulafungin, and linezolid for suspected hospital acquired pneumonia. Repeat blood cultures and additional infectious disease studies were sent. Over the next 48 hours, her oxygen requirements increased to heated high flow oxygen with an fiO2 of 60%. Patient and family declined bronchoscopy, intensive care unit transfer, and the patient was transitioned to comfort care. She expired on hospital day nine. Postmortem, her blood cultures, 1, 3 beta-D glucan, and serology studies returned with Coccidiodes immitis. Review of primary care provider notes found that the patient was visiting family in Mexico prior to admission.

Discussion: The National Academies of Sciences, Engineering, and Medicine define diagnostic error as the failure to establish an accurate and timely explanation of the patient’s health problem or communicate that explanation to the patient. This can be further classified as a delayed, wrong, or missed diagnosis. Delayed diagnostic error is the most common type of error made, yet the term “delay” lends itself to subjectivity as no guidelines exist to quantify a reasonable delay from an unreasonable delay. This case illustrates a complex example of a delayed diagnostic error. During a retrospective chart review, no travel history was obtained by the primary team or consulting teams. Additionally, fungal studies were not ordered until hospital day seven despite the patient’s history of predominantly pulmonary symptoms on admission and immunocompromised status as a renal transplant recipient. If a travel history had been included as part of the patient’s social history, then the diagnosis could have been made sooner though the outcome may very well have been the same. Coccidiodes is endemic in parts of California, Arizona, Texas, New Mexico, Mexico, and parts of Central and South America. The incubation period is 1-3 weeks and clinical manifestation can vary from no symptoms to pulmonary disease, dissemination, and death. High risk patient groups include the elderly and those with diabetes mellitus, multiple co-morbidities, and immunocompromising conditions. The preferred treatment is fluconazole or amphotericin B for severe disease.

Conclusions: Unfortunately, diagnostic errors are common, costly, and dangerous to patients. Due to the complexities of the diagnostic process, providing real time feedback to clinicians and creating systems to mitigate this is an evolving process that requires more research and a close examination of the healthcare infrastructure.

IMAGE 1: CT Chest