SHM Converge Scientific Abstract ePoster Gallery-An Unusual Case of Streptococcal Pharyngitis

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This case describes a 24-year-old man who presented with fever, sore throat, mouth and gum tenderness, and lightheadedness after being diagnosed with streptococcal pharyngitis and started on penicillin three days earlier. In the emergency department he was febrile and tachycardic, with mild cervical lymphadenopathy and pharyngeal erythema. Laboratory testing showed severe leukopenia and agranulocytosis (WBC 1.8, ANC 0), while hemoglobin, platelets, and chemistry were normal.<br /><br />He was admitted and treated for febrile neutropenia with IV antibiotics. Hematology was consulted, and the initial leading explanations were acute streptococcal infection or a viral illness. On hospital day 4, he received filgrastim and underwent a bone marrow biopsy, which showed hypocellular marrow with trilineage hematopoiesis and no malignancy, consistent with recovery after a transient insult. His white count and oral symptoms improved. Only after additional history was obtained did he disclose cocaine use while on vacation.<br /><br />The presentation highlights diagnostic cognitive errors, especially anchoring bias and premature closure, where clinicians may lock onto an early diagnosis and stop reconsidering alternatives. The case emphasizes the importance of reassessing the diagnosis, seeking additional history when findings do not fit, and being aware of system factors such as time pressure that can worsen diagnostic error.<br /><br />A key teaching point is that levamisole, a common cocaine adulterant, can cause agranulocytosis and sometimes vasculitis; about half of reported cases present with oropharyngeal symptoms. The presentation concludes by encouraging clinicians to develop awareness of cognitive bias, consider alternative diagnoses, reflect on reasoning, and implement training and systems that support better diagnostic decision-making.

Asset Subtitle

Christina Kahl

Meta Tag

Author List Christina Kahl

Category Clinical Vignettes

Concept Cognitive Bias

Concept Anchoring Bias

Concept Premature Closure

Concept Febrile Neutropenia

Concept Diagnostic Reasoning

Distinguished Non-Finalist

Presenter Organization University of North Carolina at Chapel Hill

Presenting Author Christina Kahl

Track Adult

Keywords

agranulocytosis

febrile neutropenia

levamisole

cocaine adulterant

anchoring bias

premature closure

diagnostic error

bone marrow biopsy

streptococcal pharyngitis

filgrastim

Cognitive Bias

Anchoring Bias

Premature Closure

Febrile Neutropenia

Diagnostic Reasoning