A 30‐year‐old Mexican male, presented to the emergency department with a two‐month history of productive cough, fever up to 101.0 F, hemoptysis, night sweats, pleuritic chest pain, malaise and an unintentional weight loss of 20 pounds. He denied sick contacts and illicit drug use. Blood pressure was 136/81, pulse 87, respiratory rate 20 and temperature of 99.6. Lung examination revealed bilateral ronchi. Rest of examination was unremarkable. Genitourinary examination was deferred. Chest X‐ray revealed bilateral infiltrates with possible underlying masses. Presumed diagnosis was tuberculosis or community acquired pneumonia. AFB smears and HIV test were ordered, both were negative. On the third day of hospitalization, since no significant improvement was noted, a CT was ordered which revealed bilateral necrotic masses. Considering metastatic disease with primary from testicles, we ordered a scrotal ultrasound, which identified a 7.4 x 4.5 cm mass replacing the right testicle. Right orchiectomy was performed and the diagnosis of choriocarcinoma with lung metastasis was made. Chemotherapy led to marked improvement.
Hemoptysis has a broad differential diagnosis dominated by concerns of cancer and tuberculosis. The differential diagnosis is significantly narrowed with appropriate demographic data and smoking history. However, when pertinent history and physical findings are overlooked or missed, diagnostic errors may occur. Diagnostic errors, the new frontier in patient safety, result in delay of diagnosis, increased cost, and a substantial amount of adverse events. Heuristics such as Beck’s triad facilitate decision‐making, allowing for quick diagnosis. However, when features are incomplete or confounding, a misdiagnosis may occur. In this case, the heuristic was Mexican with fever and hemoptysis equals tuberculosis; rather than young man with scrotal mass and lung lesions, equals tumor.
Physicians must proactively work to avoid diagnostic errors by performing their own history and physical, being mindful about the differential and expecting errors.
To cite this abstract:Clarke A, Lopez‐Vasquez M, Hanley J. Hemoptysis and Fever in a Young Mexican Equals Tuberculosis? The Path to a Diagnostic Error. Abstract published at Hospital Medicine 2014, March 24-27, Las Vegas, Nev. Abstract 360. Journal of Hospital Medicine. 2014; 9 (suppl 2). https://www.shmabstracts.com/abstract/hemoptysis-and-fever-in-a-young-mexican-equals-tuberculosis-the-path-to-a-diagnostic-error/. Accessed March 31, 2020.