Phenomena known as cognitive biases, when applied to the details of a patient’s medical history, evidently steered the first attempts at diagnosis in the wrong direction. A 60-year-old man presented after 6 weeks of progressively worsening fevers, weight loss, malaise, night sweats, and confusion. Originally, the fevers were intermittent and low grade at 37.7°C (99.9°F). In the 2 weeks prior to presentation, they occurred daily, with temperatures rising to 39°C (102°F). The patient also reported mild headaches, a dry cough, and palpable lymphadenopathy in his axilla and neck. His medical history was remarkable for a traumatic brain injury and chronic lymphocytic leukemia, which had been treated previously with 5 cycles of fludarabine, cyclophosphamide, and rituximab.
Over the prior month, the patient visited the emergency department multiple times for these concerns. His signs and symptoms were attributed first to a viral infection. At that time, computed tomography (CT) of the chest revealed multiple bilateral pulmonary nodules and extensive adenopathy. The imaging report read “consistent with metastatic disease likely related to patient’s chronic lymphocytic leukemia” (Figure 1). He was discharged home from the emergency department.
He presented again after experiencing a seizure, but noncontrast-enhanced CT of the head revealed prior evidence of traumatic brain injury without any acute findings. His partner reported a temperature of 38.4°C (101.1°F) shortly before the event. The seizure was attributed to fever, and he was discharged home. He continued to have progression of malaise, weight loss, and confusion, prompting admission to the hospital out of concern for recurrence of his chronic lymphocytic leukemia.
Assessment
Afebrile at first, the patient developed a fever of 38.3°C (101°F) that evening. He was nontachycardic, normotensive, and nonhypoxic. Although he was in no apparent distress, he appeared confused, with a tangential and nonsensical thought process bordering on word salad. He had no nuchal rigidity but had diffuse lymphadenopathy. His left wrist had an erythematous, ulcerated, papulonodular lesion (Figure 2), and his left upper arm and back showed additional 3-5 mm, nonulcerated, erythematous, papular lesions. He had an unremarkable pulmonary examination and a nonfocal neurologic examination.
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-Jessica Haraga, MD, Melissa LeBlanc, MD, Joseph Chiovaro, MD
This article originally appeared in the December issue of The American Journal of Medicine.
