SHM Converge Scientific Abstract ePoster Gallery-A Case of Red Herring

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This case describes a 76-year-old man with mantle cell lymphoma who had recently completed chemotherapy and presented to an outside emergency department with generalized weakness, hypotension, and hypoglycemia. Initial evaluation showed anemia, thrombocytopenia, and a positive fecal occult blood test, leading clinicians to suspect gastrointestinal bleeding as the main cause of his illness. He was transferred to the ICU for further care.<br /><br />However, the true problem was a missed or delayed recognition of severe metabolic derangements consistent with tumor lysis syndrome. Key abnormalities included profound metabolic acidosis, acute kidney injury, hyperkalemia, hyperphosphatemia, and markedly elevated uric acid and lactate levels. These findings, along with his recent chemotherapy and underlying hematologic malignancy, strongly suggested tumor lysis syndrome rather than GI bleed.<br /><br />The case highlights three related diagnostic errors: failure to act on critical lab abnormalities, over-weighting the positive fecal occult blood test, and delayed consideration of tumor lysis syndrome. The positive stool test became a “red herring” that contributed to diagnostic anchoring and diverted attention from the more urgent metabolic crisis.<br /><br />Because recognition was delayed, the patient deteriorated rapidly. He required emergent intubation and suffered aspiration during bronchoscopy, then progressed to multiorgan failure. Despite aggressive treatment, he died after transition to comfort care.<br /><br />The authors conclude that earlier correlation of laboratory findings with the clinical context might have led to faster diagnosis and treatment of tumor lysis syndrome. While it is uncertain whether earlier intervention would have prevented death, the delay likely contributed to the poor outcome and was potentially avoidable.

Asset Subtitle

Gururaj J. Kolar

Meta Tag

Author List Gururaj J. Kolar, Jennifer Kleinman Sween, Katie M. Rieck, M. Caroline Burton, Riddhi S. Parikh, Robert W. Kirchoff, Sagar B Dugani

Category Clinical Vignettes

Concept Metabolic Acidosis

Concept Tumor Lysis Syndrome

Concept Diagnostic Anchoring

Concept Anion Gap Metabolic Acidosis

Concept Multiorgan failure

Distinguished Non-Finalist

Presenter Organization Mayo Clinic

Presenting Author Gururaj J. Kolar

Track Adult

Keywords

mantle cell lymphoma

tumor lysis syndrome

chemotherapy

metabolic acidosis

acute kidney injury

hyperkalemia

hyperphosphatemia

diagnostic error

gastrointestinal bleeding

fecal occult blood test

Metabolic Acidosis

Tumor Lysis Syndrome

Diagnostic Anchoring

Anion Gap Metabolic Acidosis

Multiorgan failure