ANCHORING BIAS DURING THE COVID-19 PANDEMIC

Abstract

TOPIC: Chest Infections TYPE: Medical Student/Resident Case Reports INTRODUCTION: Patients presenting in New York City, the epicenter for COVID in the United States, with severe hypoxic respiratory failure in the past year with acute respiratory distress syndrome (ARDS) signs were thought to exclusively have COVID-19 pneumonia. Even if initial tests were negative, physicians often anchored on the diagnosis of COVID as the disease was rapidly spreading and hospitals were at maximum capacity. We present a case of a young male who presented with severe hypoxic respiratory failure in the early stages of the pandemic who was found to be negative for COVID-19 and subsequently found to have pneumocystis jiroveci pneumonia (PJP). CASE PRESENTATION: This is a 42 year-old male with a past medical history of controlled diabetes mellitus type 2, hypertension, and a previous smoker who presented with worsening progressive shortness of breath for three days. On admission, the patient was found to be tachycardic, tachypneic and hypoxic. Chest x-ray showed bilateral diffuse infiltrates most consistent with ARDS. ABG revealed severe hypoxia with PO2 of 39 on room air. He was initially placed on bi-level with minimal improvement and was subsequently intubated. Initial oropharyngeal and nasopharyngeal COVID-19 swabs were negative. His influenza PCR also resulted as negative. Sputum cultures, endotracheal aspirate and blood cultures all returned back negative. On day three of his admission, the patient was tested for HIV and found to be positive with CD4 count <50. He was started on TMP-SMX and methylprednisolone for suspected PJP pneumonia. Due to fears from the ongoing and heightening pandemic, the patient was tested yet again for COVID swab and it resulted negative. He underwent a bronchoscopy with BAL which confirmed the diagnosis of PJP. Patient continued to improve on antibiotics, was eventually extubated, and started on antiretroviral therapy with improvement of CD4 at three month follow-up. DISCUSSION: Physicians have become blinded from the COVID pandemic and often anchor to the diagnosis of severe hypoxic respiratory failure from COVID-19. Other diseases such as PJP can present similarly and prompt treatment is necessary. PJP has a high morbidity and mortality rate amongst immunocompromised patients and remains a leading opportunistic infection in AIDS patients. Our patient was a school teacher who denied any intravenous drug abuse or high-risk sexual encounters. CONCLUSIONS: Although many patients present with severe hypoxic respiratory distress and require mechanical ventilation during the ongoing COVID-19 pandemic, it is important to rule out other infectious causes of ARDS such as PJP which can also lead to morbid outcomes if not treated appropriately. REFERENCE #1: Gaborit BJ, Tessoulin B, Lavergne RA, et al. Outcome and prognostic factors of Pneumocystis jirovecii pneumonia in immunocompromised adults: a prospective observational study. Ann Intensive Care. 2019;9(1):131. Published 2019 Nov 27. doi:10.1186/s13613-019-0604-x REFERENCE #2: Harris, J.R., Balajee, S.A. & Park, B.J. Pneumocystis Jirovecii Pneumonia: Current Knowledge and Outstanding Public Health Issues. Curr Fungal Infect Rep 4, 229–237 (2010). https://doi.org/10.1007/s12281-010-0029-3 DISCLOSURES: No relevant relationships by Sahar Ilyas, source=Web Response No relevant relationships by Navim Mobin, source=Web Response No relevant relationships by Nisha Patel, source=Web Response No relevant relationships by Michal Tokarski, source=Web Response