SHM Converge Scientific Abstract ePoster Gallery-Delayed Pneumocystis Pneumonia Diagnosis- Analyzing Diagnostic Errors

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This case describes a 71-year-old immunocompromised woman with multiple comorbidities who presented with worsening cough, fever, mild hemoptysis, and shortness of breath. Her CT chest showed mostly perihilar infiltrates, and she was initially treated for community-acquired pneumonia. Despite broadening antibiotics, her respiratory status rapidly worsened, requiring intubation and ICU transfer.<br /><br />Bronchoscopy was performed, and BAL samples were sent for testing, but Pneumocystis jirovecii (PJP) staining was not ordered initially. Key clues included markedly elevated LDH and later a strongly positive Fungitell test. However, the PJP PCR result from BAL took several days to return, and the diagnosis was delayed until hospital day 7. Treatment was then started with Bactrim and steroids, but the patient developed severe complications including drug fever, hemolytic anemia, thrombocytopenia, and upper GI bleeding. Her condition continued to deteriorate, and care was eventually shifted to comfort measures.<br /><br />The authors use this case to examine diagnostic error through the DEER taxonomy. Contributing factors included underweighting of clinical history and laboratory data, delayed ordering of the correct tests, delayed consultation, and delayed consideration of Pneumocystis pneumonia. Cognitive biases such as anchoring and premature closure likely played a role.<br /><br />The main lesson is that in immunocompromised patients with classic imaging findings and elevated LDH, clinicians should maintain a high suspicion for Pneumocystis pneumonia. When appropriate, traditional staining of BAL or induced sputum may provide faster results than PCR and could prevent dangerous diagnostic delays. Debiasing strategies, including slowing down clinical reasoning, using metacognition, and applying checklists, may help reduce similar errors.

Asset Subtitle

Krithika Suri

Meta Tag

Author List Deepak Vedamurthy, Krithika Suri, Tea Ramishvili

Category Clinical Vignettes

Concept Pneumocystis jirovecii pneumonia

Concept Immunosuppressed Patients

Concept Diagnostic Error

Concept Clinical Feature

Concept Imaging Finding

Distinguished Non-Finalist

Presenter Organization Christiana Hospital| Thomas Jefferson University

Presenting Author Krithika Suri

Track Adult

Keywords

Pneumocystis jirovecii pneumonia

immunocompromised patient

diagnostic delay

bronchoalveolar lavage

PCR testing

elevated LDH

Fungitell test

anchoring bias

premature closure

DEER taxonomy

Pneumocystis jirovecii pneumonia

Immunosuppressed Patients

Diagnostic Error

Clinical Feature

Imaging Finding