A photo of a young adult male grimacing and holding the left side of his back

A 21-year-old man presented to a hospital for evaluation after 7 weeks of intractable left back pain on referral from an outside provider. He had spent the last 3 weeks hospitalized in another facility due to severe back pain. During this time he developed fever and pyuria; Urinalysis showed susceptible Escherichia coli infection treated with doripenem for 2 weeks. His fever subsided, but his back pain persisted.

Although his clinical condition improved to some extent, laboratory tests performed at the referring facility showed his serum albumin level to be 1.8 g/dl (normal range 4.1 to 5.1 g/dl) and his C-reactive Protein (CRP) level was 7.8 mg/dL (normal range

At his initial assessment, the patient reported an unexplained weight loss of 5 kg and diarrhea up to 5 times a day for the past 2 years. He did not report any joint, abdominal, or muscle pain; loss of appetite; Vomit; hardships; urinary symptoms; blood in his stool; or high-risk sex history.

On physical examination, physicians noted that the patient appeared healthy, alert, and aware of time and place. His temperature was 37.0 °C, his pulse was 98 beats/minute, his blood pressure was 104/59 mm Hg, his respiratory rate was 14 breaths/minute and his oxygen saturation in room air was 98%.

Pulmonary and cardiac examination findings were unremarkable, and there was no evidence of swelling or skin abnormalities. His abdomen was soft and flat with slight tympanic murmurs. Palpation showed slight tenderness in the right upper quadrant, but there were no signs of muscular defense or tenderness. However, the patient had left costovertebral joint angle tenderness.

Under the results of urinalysis, the urine protein content was 1.92g/g Cre (normal range

The blood test results showed that his CRP level was now 6.3 mg/dl and his serum albumin level was still 1.8 g/dl. Laboratory test results showed that the patient’s liver function was within normal limits.

Doctors diagnosed the patient with a urinary tract infection (UTI) complicated with pyelonephritis. Given his persistent diarrhea and increased inflammatory response, they suspected he also had inflammatory bowel disease. To investigate this further, they performed a colonoscopy, which showed numerous longitudinal ulcers and crack lesions. The results of the biopsy suggested a diagnosis of Crohn’s disease (CD). The patient then underwent abdominal radiography and echography to rule out possible postoperative perforation.

Due to the patient’s reported history of pain associated with scoliosis, he was prescribed treatment with nonsteroidal anti-inflammatory drugs.

Three days after his colonoscopy, the patient presented to the emergency department again and reported recurrent fever and worsening back pain. Urinalysis on this occasion identified fecaluria which the clinicians suspected was due to a vesicointestinal fistula.

The team re-examined the CT images provided by the referring hospital. These showed air in the bladder, which doctors believed could also be due to a CD-related vesicointestinal fistula; The patient underwent a contrast enema which confirmed the presence of a vesicointestinal fistula.

Figure. X-ray bowel studies with barium enteroclysis. Oral contrast was seen simultaneously in the small and large intestine and in the urinary bladder (arrow).

The patient was admitted for examination of the fistula and started treatment with tazobactam/piperacillin (4.5 g every 6 hours) and oral mesalazine (3 g/day). Fourteen days later, he underwent laparoscopic resection of the terminal ileum for stenosis, with spontaneous closure of the fistula facilitated only by medical management.

After an additional 2 weeks of observation, the patient had no postoperative complications and was discharged from the hospital. There was no recurrence of UTIs during ongoing follow-up visits every 3 months.

discussion

Clinicians presenting this case of a 21-year-old man with persistent UTI despite 3 weeks of antibiotic treatment noted that the case “presents a clear and interesting example of cognitive biases, including satisfaction and anchoring biases, i.e., finding a disease that the discovery of which prevents the accurate and timely diagnosis of another.”

Although the series of diagnostic errors that delayed the diagnosis of the patient’s CD began with “the referring physician’s deficiency”. [of] Knowledge of complicated UTIs and their epidemiology in young men,” the case authors acknowledged their own oversight in not examining the patient for possible anatomical causes of the UTI.

They found that their delay in accessing and interpreting the original imaging studies, which showed free air in the bladder, caused them to mis-base their original diagnosis. Subsequently, the discovery of the patient’s history of chronic diarrhea “led to the diagnosis of Crohn’s disease via colonoscopy, [which] created our satisfaction bias.” This error could be avoided with a thorough physical examination, they added.

“We did not consider the complications of CD, such as the formation of fistulas,” they wrote, noting that this turned out to be “the cause of this patient’s recurrent UTI.”

Finally, the fact that they incorrectly attributed the patient’s low back pain to a reported pre-existing scoliosis without conducting a detailed assessment of this symptom resulted in “delayed emergency care for the now-recognized vesicointestinal fistula,” they added.

According to a multicenter retrospective study of CD patients, 75% of entero-urinary fistulas were diagnosed in men.

In addition, all CD patients with urinary tract fistulas from a single-center analysis had “fistulas from the ileum (64%), colon (21%), rectum (8%), and multiple sites (7%). Sites included bladder (88%), urethra (6%), urachus (3%), ureter (1%) and other (1%).”

The group reported this case to encourage physicians to consider several aspects of the diagnostic process: the frequency and percentage of disease; Recognizing that a disease can be identified by both its organ-specific pathology and its adverse effects on adjacent organ systems; the importance of focusing on patient concerns through the use of standard review of systems, as opposed to “anchoring on data provided by referral agencies, which may be qualitative and lack useful patient-centric information”; and vigilance for their own satisfaction and entrenchment of prejudice.

To avoid the influence of bias, the authors advised physicians to begin with “a careful interview and physical examination as if the patient were a first-time patient.” In conclusion, they emphasized the importance of making “calm decisions with each patient and each case” and recommended the use of a “checklist or problem list for complicated patient diagnosis and treatment.”

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    Kate Kneisel is a freelance medical journalist based in Belleville, Ontario.

disclosure

The authors declared no conflicts of interest.

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