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Beyond the Crisis: Diagnostic Bias in a Sickle Cell Patient With Overlapping Pathologies
Background
Sickle cell disease (SCD) patients often present with pain and fever, commonly attributed to vaso-occlusive crises (VOC), which can delay the diagnosis of other conditions. This highlights the need for reassessment and bias-aware clinical reasoning.
Case Presentation
A 27-year-old male with SCD, prior hip replacement, and cholecystectomy presented with whole-body pain. Labs supported VOC with anemia, elevated LDH, and reticulocytosis. Despite RUQ tenderness and a positive Murphy sign, the ultrasound was unremarkable, and he was admitted for VOC management. Persistent fever >48 hours prompted further evaluation with MRCP, revealing choledocholithiasis with common bile duct and mild biliary dilatation; later, his pain and fever resolved by ERCP, and he was discharged. However, he returned the following day with whole-body and right upper quadrant pain; lab tests showed normal hemoglobin, LDH, and reticulocyte levels, indicating no active sickling. On follow-ups, the patient started to have fever episodes again. Subsequent fevers prompted a CT scan, revealing pulmonary embolism involving the right interlobar pulmonary artery extending into the segmental and subsegmental vessels and right lower lobe pneumonia. He denied any cough or shortness of breath. Treatment with Eliquis for the embolism and antibiotics for hospital-acquired pneumonia resolved the fever and leukocytosis, but the patient persistently requested high-dose opioids despite normal sickling labs.
Discussion
This case highlights the need for diagnostic flexibility in SCD, as anchoring bias may cause clinicians to overlook other life-threatening conditions when VOC is suspected. The patient’s symptoms, initially suggestive of VOC, were later linked to choledocholithiasis, pulmonary embolism, and pneumonia, highlighting how overlapping complications can be misattributed to a single episode. The delayed diagnosis reflects cognitive and systemic factors, with few reports emphasizing the diagnostic delays when multiple SCD-related complications occur together. The stigma surrounding opioid use may also hinder timely care escalation. This case highlights the need for structured reassessment, red-flag criteria, and multidisciplinary collaboration to improve diagnostic accuracy and prevent fatal delays in complex SCD presentations.
Conclusions
This case emphasizes reassessing persistent symptoms in SCD, avoiding anchoring bias, and recognizing red flags. Multidisciplinary evaluation and bias-aware practices are key to accurate, timely care.
Background
Sickle cell disease (SCD) patients often present with pain and fever, commonly attributed to vaso-occlusive crises (VOC), which can delay the diagnosis of other conditions. This highlights the need for reassessment and bias-aware clinical reasoning.
Case Presentation
A 27-year-old male with SCD, prior hip replacement, and cholecystectomy presented with whole-body pain. Labs supported VOC with anemia, elevated LDH, and reticulocytosis. Despite RUQ tenderness and a positive Murphy sign, the ultrasound was unremarkable, and he was admitted for VOC management. Persistent fever >48 hours prompted further evaluation with MRCP, revealing choledocholithiasis with common bile duct and mild biliary dilatation; later, his pain and fever resolved by ERCP, and he was discharged. However, he returned the following day with whole-body and right upper quadrant pain; lab tests showed normal hemoglobin, LDH, and reticulocyte levels, indicating no active sickling. On follow-ups, the patient started to have fever episodes again. Subsequent fevers prompted a CT scan, revealing pulmonary embolism involving the right interlobar pulmonary artery extending into the segmental and subsegmental vessels and right lower lobe pneumonia. He denied any cough or shortness of breath. Treatment with Eliquis for the embolism and antibiotics for hospital-acquired pneumonia resolved the fever and leukocytosis, but the patient persistently requested high-dose opioids despite normal sickling labs.
Discussion
This case highlights the need for diagnostic flexibility in SCD, as anchoring bias may cause clinicians to overlook other life-threatening conditions when VOC is suspected. The patient’s symptoms, initially suggestive of VOC, were later linked to choledocholithiasis, pulmonary embolism, and pneumonia, highlighting how overlapping complications can be misattributed to a single episode. The delayed diagnosis reflects cognitive and systemic factors, with few reports emphasizing the diagnostic delays when multiple SCD-related complications occur together. The stigma surrounding opioid use may also hinder timely care escalation. This case highlights the need for structured reassessment, red-flag criteria, and multidisciplinary collaboration to improve diagnostic accuracy and prevent fatal delays in complex SCD presentations.
Conclusions
This case emphasizes reassessing persistent symptoms in SCD, avoiding anchoring bias, and recognizing red flags. Multidisciplinary evaluation and bias-aware practices are key to accurate, timely care.
Background
Sickle cell disease (SCD) patients often present with pain and fever, commonly attributed to vaso-occlusive crises (VOC), which can delay the diagnosis of other conditions. This highlights the need for reassessment and bias-aware clinical reasoning.
Case Presentation
A 27-year-old male with SCD, prior hip replacement, and cholecystectomy presented with whole-body pain. Labs supported VOC with anemia, elevated LDH, and reticulocytosis. Despite RUQ tenderness and a positive Murphy sign, the ultrasound was unremarkable, and he was admitted for VOC management. Persistent fever >48 hours prompted further evaluation with MRCP, revealing choledocholithiasis with common bile duct and mild biliary dilatation; later, his pain and fever resolved by ERCP, and he was discharged. However, he returned the following day with whole-body and right upper quadrant pain; lab tests showed normal hemoglobin, LDH, and reticulocyte levels, indicating no active sickling. On follow-ups, the patient started to have fever episodes again. Subsequent fevers prompted a CT scan, revealing pulmonary embolism involving the right interlobar pulmonary artery extending into the segmental and subsegmental vessels and right lower lobe pneumonia. He denied any cough or shortness of breath. Treatment with Eliquis for the embolism and antibiotics for hospital-acquired pneumonia resolved the fever and leukocytosis, but the patient persistently requested high-dose opioids despite normal sickling labs.
Discussion
This case highlights the need for diagnostic flexibility in SCD, as anchoring bias may cause clinicians to overlook other life-threatening conditions when VOC is suspected. The patient’s symptoms, initially suggestive of VOC, were later linked to choledocholithiasis, pulmonary embolism, and pneumonia, highlighting how overlapping complications can be misattributed to a single episode. The delayed diagnosis reflects cognitive and systemic factors, with few reports emphasizing the diagnostic delays when multiple SCD-related complications occur together. The stigma surrounding opioid use may also hinder timely care escalation. This case highlights the need for structured reassessment, red-flag criteria, and multidisciplinary collaboration to improve diagnostic accuracy and prevent fatal delays in complex SCD presentations.
Conclusions
This case emphasizes reassessing persistent symptoms in SCD, avoiding anchoring bias, and recognizing red flags. Multidisciplinary evaluation and bias-aware practices are key to accurate, timely care.