Case Presentation: Our patient is a 74-year-old male with a history of thrombocytopenia thought secondary to ITP, hypothyroidism, and prior spontaneous coronary artery dissection requiring cardiac bypass who was transferred from an outside hospital for acute kidney injury and abdominal distention. A few weeks prior to admission, the patient experienced congestion, cough and low-grade fever that subsided. He then developed abdominal distension with exertional dyspnea and constipation. On arrival, clinical exam was remarkable for abdominal distention accompanied by bilateral lower extremity edema. Admission labs were relevant for elevated AST, creatinine of 1.91 (Baseline of 0.9), BUN of 47, and platelet count of 104. He was found to be IgG positive for EBV nuclear antigen, IgM negative. Given his dyspnea with a prior history of SCAD and bypass, he underwent extensive cardiac work up including an unrevealing echocardiogram. With his abdominal distention he underwent GI assessment including ERCP and EGD that revealed gastritis and duodenitis. CT abdomen noted “innumerable retroperitoneal and mesenteric lymph nodes” and splenomegaly. Lymphadenopathy was not further evaluated. The patient was transferred to our institution for continued gastrointestinal and infectious disease evaluation. Given the framing of the patient’s primary chief complaint and problem representation, the admitting team was largely focused on further assessment of underlying gastrointestinal source. Initial treatment was begun for constipation with aggressive bowel regimen. The patient’s thrombocytopenia and acute anemia were largely ignored, with the patients AKI contributed to contrast induced nephropathy. The patients elevated D-dimer, ferritin and CRP were not listed as problems for evaluation when the patient was handed off across hospitals. The patient eventually required hemodialysis in the MICU. Here, the patient underwent lymph node and subsequent bone marrow biopsy revealing mantle cell lymphoma and myelodysplastic syndrome. Despite starting chemotherapy, the patient developed HLH in response to his underlying hematologic malignancy and given lack of alternative therapeutic options elected to pursue comfort care and passed.
Discussion: The above case demonstrates the risks associated with interhospital transfers outlined by Sokol-Hessner et .al including more time in the ICU, face increased inpatient mortality and lengthier overall hospital stay1. Given the admitting team’s focus on his gastrointestinal complaints and treatment for constipation there was a delay in lymph node biopsy that revealed his underlying diagnosis. This demonstrates the team’s framing effect bias and continued delay in diagnosis of his mantle cell lymphoma.
Conclusions: The management of hospitalized patients is complex, requiring extensive medical work up. While a clinical diagnosis is desired, hospital workup can be costly and unnecessary, muddling the clinical picture. In particular, interhospital transfers carry multiple diagnostic biases given the extent of prior medical investigation including anchoring and framing effect, in which diagnosticians are more likely to explore things given the way in which things are framed2. Healthcare teams must continue to expand their differential diagnosis when patients are transferred from outside facilities when evaluation is ongoing to avoid missed diagnoses and delay in care.