SHM Converge Scientific Abstract ePoster Gallery-It's Not All in the Head: Cognitive Bias in the Diagnosis of Ataxia

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This case describes a 40-year-old woman with bipolar disorder and substance use disorder who presented with headache, dizziness, vomiting, and progressively worsening ataxia. Because of her psychiatric and substance use history, her initial neurologic symptoms were partly minimized and attributed to behavioral or non-neurologic causes. Brain CT and MRI showed multiple cystic lesions, which were initially interpreted as suspicious for neurocysticercosis. This led to anchoring and confirmation bias, with clinicians focusing on infectious testing and delaying broader evaluation.<br /><br />Her infectious workup, including cysticercosis antibody testing, was negative. Further imaging revealed necrotic mediastinal lymph nodes and an endobronchial lesion. Endobronchial ultrasound-guided biopsy confirmed small cell neuroendocrine carcinoma, consistent with small cell lung cancer (SCLC). The final diagnosis was SCLC with cystic brain metastases.<br /><br />The case highlights several diagnostic pitfalls: stigmatization of patients with psychiatric illness and substance use disorders, overreliance on a radiologic impression, and premature closure before considering malignancy. Although cystic brain lesions can suggest infection, metastatic disease must remain in the differential, even in younger patients with nonspecific neurologic symptoms. SCLC is an aggressive cancer that frequently metastasizes to the brain, and this diagnosis should be considered when imaging findings are atypical or the clinical course worsens.<br /><br />Treatment included dexamethasone and levetiracetam initially, followed by whole brain radiation and chemotherapy with etoposide and carboplatin. The case emphasizes the importance of maintaining diagnostic breadth and avoiding cognitive bias in complex neurologic presentations.

Asset Subtitle

Shipra Shrestha

Meta Tag

Author List Bibhuti Adhikari, Robert Thompson, Shipra Shrestha, Youssef Samaha

Category Clinical Vignettes

Concept Small Cell Lung Carcinoma

Concept Diagnostic Bias

Concept Cognitive Bias

Concept Anchoring Bias

Concept Confirmation Bias

Distinguished Finalist

Presenter Organization Icahn School of Medicine at Mount Sinai-Elmhurst Hospital Center

Presenting Author Shipra Shrestha

Track Adult

Keywords

small cell lung cancer

cystic brain metastases

neurocysticercosis

diagnostic bias

psychiatric stigma

substance use disorder

ataxia

brain imaging

endobronchial biopsy

whole brain radiation

Small Cell Lung Carcinoma

Diagnostic Bias

Cognitive Bias

Anchoring Bias

Confirmation Bias