SHM Converge Scientific Abstract ePoster Gallery-Any Recent Travel?: a Case of Delayed Diagnosis

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This case describes an 82-year-old renal transplant recipient with diabetes and hypertension who was admitted with chills, cough, dyspnea, and urinary symptoms. She was initially diagnosed with cystitis and treated empirically with meropenem after urinalysis showed pyuria and hematuria. Her admission chest X-ray was read as normal, but by hospital day 6 she developed fever, leukocytosis, and worsening oxygen needs. CT imaging then showed multifocal airspace opacities and small bilateral effusions, prompting broader antibacterial and antifungal coverage for presumed hospital-acquired pneumonia. Despite escalation, her respiratory status worsened, and she died on hospital day 9 after goals of care shifted to comfort measures.<br /><br />Postmortem blood cultures and serologic testing identified Coccidioides immitis, revealing that the true diagnosis had been missed. Retrospective chart review showed she had recently traveled to Mexico, an endemic area, but this history was not obtained by either the primary or consulting teams. Fungal testing was not sent until hospital day 7, despite her immunocompromised status and predominant pulmonary symptoms.<br /><br />The case highlights diagnostic error, defined as failure to establish or communicate an accurate and timely explanation for a patient’s illness. It emphasizes that delayed diagnosis is common and often subjective, with no clear standards for what constitutes an unacceptable delay. The discussion reviews coccidioidomycosis: it is endemic in parts of the southwestern United States, Mexico, and Central and South America; it may cause anything from mild respiratory illness to disseminated, fatal disease; and risk is higher in older adults, patients with diabetes, and immunocompromised individuals. Recommended treatment includes fluconazole or amphotericin B for severe infection.<br /><br />Overall, the case underscores the importance of obtaining travel history, considering endemic fungal infections early, and improving diagnostic systems to reduce preventable harm.

Asset Subtitle

Li-Kheng Ngov

Meta Tag

Author List Anunta Virapongse, Hemali Patel, Li-Kheng Ngov

Category Clinical Vignettes

Concept Coccidioidomycosis

Concept Diagnostic Error

Concept Clinical Presentation

Concept Diagnostic Delay

Concept Delayed Diagnosis

Distinguished Non-Finalist

Presenter Organization University of Colorado

Presenting Author Li-Kheng Ngov

Track Adult

Keywords

coccidioidomycosis

renal transplant

diagnostic error

hospital-acquired pneumonia

immunocompromised

travel history

Mexico

fungal infection

fluconazole

amphotericin B

Coccidioidomycosis

Diagnostic Error

Clinical Presentation

Diagnostic Delay

Delayed Diagnosis