Deming M, Mark A, Nyemba V, Heil E L, Palmeiro R M, Schmalzle S A
University of Maryland Medical Center, Department of Medicine, Division of Infectious Disease, 22 South Greene St, Baltimore, MD 21201, United States.
Institute of Human Virology, University of Maryland School of Medicine, 725 W Lombard Street, Baltimore, MD 21201, United States.
IDCases. 2019 Jul 5;18:e00588. doi: 10.1016/j.idcr.2019.e00588. eCollection 2019.
Cryptococcal meningitis is a potentially devastating infectious complication of immunosuppression best characterized in individuals with HIV. Early recognition of and appropriate antifungal therapy for cryptococcal meningitis has a profound effect on outcomes, but with more varied presentations in well-resourced countries recognition may be delayed. We present four cases of cryptococcal meningitis in immunosuppressed patients, each with significant delays in diagnosis. Pulling from recollections of providers and the documented chart assessments, we discuss and tabulate the cognitive biases and diagnostic errors that contributed to delay. We further explore the knowledge deficits regarding cryptococcal meningitis that appeared in these cases. Once meningitis was considered, each of these cases of cryptococcal meningitis was rapidly diagnosed. Diagnostic delay was driven by knowledge deficits, followed by common biases such as availability heuristics and premature closing. These delays could be countered by maintaining broad differential diagnoses, re-evaluating the patient presentation after recognition of immunosuppression, and early consultation of specialists. Delay in diagnosis of cryptococcal meningitis is associated with high morbidity and mortality. By exploring the various case presentations and errors made, we hope to provide a counter to some of the knowledge deficits associated with cryptococcal meningitis, and to provide actionable advice for early consultation to infectious disease specialists in order to improve outcomes.
隐球菌性脑膜炎是免疫抑制状态下一种潜在的毁灭性感染并发症，在艾滋病患者中最为典型。早期识别隐球菌性脑膜炎并给予恰当的抗真菌治疗对治疗结果有深远影响，但在资源丰富的国家，由于临床表现更为多样，识别可能会延迟。我们报告了4例免疫抑制患者的隐球菌性脑膜炎病例，每例诊断均有显著延迟。根据医护人员的回忆和病历记录评估，我们讨论并列表分析了导致诊断延迟的认知偏差和诊断错误。我们进一步探讨了这些病例中出现的关于隐球菌性脑膜炎的知识缺陷。一旦考虑到脑膜炎，这些隐球菌性脑膜炎病例均迅速得到诊断。诊断延迟是由知识缺陷导致的，其次是常见的偏差，如可得性启发法和过早下结论。通过保持广泛的鉴别诊断、在识别免疫抑制后重新评估患者表现以及尽早咨询专家，可以避免这些延迟。隐球菌性脑膜炎诊断延迟与高发病率和高死亡率相关。通过探讨各种病例表现和所犯错误，我们希望弥补一些与隐球菌性脑膜炎相关的知识缺陷，并为尽早咨询传染病专家提供可行建议，以改善治疗结果。
