Thread by @medrants

1/ #UncleBob has many thoughts about this tragic tale of diagnostic errors!
@UAB_ID @uabimres @acp @sgim @BradSpellberg @PaulSaxMD @AnaerobeSociety
Hard to Swallow | NEJM nejm.org/doi/full/10.10…

2/ In the very first aliquot we learn that we have a college student with throat pain and chills. We do not know if they were simple chills or rigors. This is actually a BIG DEAL. Rigors (shaking chills) have a high odds ratio for bacteremia.

3/ If she really had rigors, then she needed blood cultures and admission for likely bacteremia. Interesting that she had unilateral tonsillar swelling. I have only seen this once in a patient with Fusobacterium tonsillitis with bacteremia! No data, just an observation

4/ In the second aliquot, she returns with worsened pain. We published a case report and provided the differential diagnosis for worsened pain, since most pharyngitis improves within 3-5 days. Severe Acute Pharyngitis Caused by Group C Streptococcus dx.doi.org/10.1007/s11606…

5/ Next neither discussant nor physicians seeing her acknowledge that the differential diagnosis of significant tonsillo-pharyngitis in adolescents is more than group A strep. We must consider group C/G strep, Fusobacterium necrophorum, mono syndromes & acute HIV

6/ My pet peeve - steroids in this situation. I know that the emergency physicians like this. It generally improves symptoms, but I worry about masking a more serious infection - like this one.

7/ Like the discussant, I really have wanted a neck CT with muffled voice and unilateral enlargement. She keeps getting worse, she has increased WBC - still no CT. She c/o dyspnea - no CXR. Aaarggghh

8/ When finally admitted the story SCREAMS the Lemierre Syndrome - low platelets are classic. She has been toxic and c/o dyspnea. I think too much emphasis has been given to the normal pulse Ox.

9/ Why is this case so infuriating - because we have done such a poor job of teaching the fundamentals to make this diagnosis earlier! Sore throats are usually very simple - system 1 thinking. But sometimes they require system 2 thinking - like this case.

10/ My big takeaways:
Distinguish chills from rigors. Rigors = immediate blood cultures and IV antibiotics
Know the different differential diagnosis of adolescent/young adult pharyngo-tonsillitis

11/
Know the natural history of pharyngo-tonsillitis - and be prepared to "attack" when the symptoms are worsening. The attack should include thinking about diagnosis, and a strong consideration of imaging.

12/ #UncleBob drops the mic, still steaming and shaking his head