Case Presentation: A 50-year-old female was admitted with shortness of breath, cough and fevers. Her past medical history was significant for breast cancer undergoing active neoadjuvant chemotherapy with doxorubicin and cyclophosphamide. She was hypoxic requiring 2L of oxygen via nasal cannula and febrile to 39.0°C. Labs revealed a WBC of 12.0 x 109/L (4.5-11.0 x 109/L) with mild lymphopenia, hemoglobin of 9.2 g/dL (12.0-16.0 g/dL), lactate of 2.3 mmol/L (<1.0 mmol/L), elevated D-dimer, and a respiratory pathogen panel positive for rhinovirus. CT chest showed a tiny non-occlusive sub-segmental pulmonary embolism for which anticoagulation was started. CT also showed bibasilar atelectasis with surrounding consolidation in the left lower lobe. She was treated with piperacillin-tazobactam for a superimposed pneumonia.Despite antibiotics and aggressive pulmonary hygiene, the patient continued to fever and had increasing oxygen requirements. Repeat chest x-ray showed worsening bilateral opacities so antibiotics were broadened to vancomycin, cefepime and azithromycin on hospital day 3. Despite this, she continued to deteriorate so bronchoscopy was performed which revealed a positive PJP smear. Trimethoprim-sulfamethoxazole and oral Prednisone were started while the other antibiotics were discontinued. Further questioning revealed that the patient was receiving high doses of dexamethasone prior to chemotherapy for nausea prevention. Within 48 hours of trimethoprim-sulfamethoxazole initiationher fevers resolved and her respiratory status improved significantly. She was weaned to room air and discharged on hospital day 10.
Discussion: This patient presented a unique diagnostic and therapeutic challenge. She was known to be immunocompromised given her chemotherapy, but initial workup yielded a reasonable diagnosis of rhinovirus with superimposed bacterial pneumonia. Given her immunocompromised state, we anticipated it may take her longer than usual to recover from a common viral infection or pneumonia. Her lack of improvement and frank worsening of her respiratory status prompted us to investigate further as it did not seem reasonable to attribute her deterioration to rhinovirus. This led to further questioning that revealed her significant steroid use, which raised concern for PJP pneumonia. This led to the assistance from pulmonology who obtained the appropriate diagnostic testing that confirmed the diagnosis, which led to successful treatment and a positive patient outcome.
Conclusions: As a hospitalist, it is important to recognize when patients are not improving as expected. Most illnesses have an anticipated course and hospitalists need to recognize when a patient’s course is not following the expected trajectory. This does not necessarily mean that an extensive additional workup is necessary every time the expected course is not followed, but we should at least pause to ask ourselves, “What could we be missing?” This exercise helps to combat anchoring bias, a bias that could have negatively impacted our patient. In this case, our patient had a presumed diagnosis supported by testing but failed to improve. Instead of anchoring on the original diagnosis, further focused questioning identified the factors that put her at risk for atypical infection, which led to the testing that correctly identified the pathogen. Once this was done adequate treatment was started, and the patient rapidly improved.