Missed Opportunities for Diagnosing Vertebral Osteomyelitis Caused by Influential Cognitive Biases

Patient: Male, 83-year-old Final Diagnosis: Vertebral osteomyelitis Symptoms: Back pain • fever Medication: — Clinical Procedure: — Specialty: Infectious Diseases OBJECTIVE: Mistake in diagnosis BACKGROUND: Vertebral osteomyelitis is a rare form of bone infection that requires prompt diagnosis and treatment; however, this is challenging because of the lack of specific symptoms and low sensitivity of diagnostic tests, especially in the early stages. Our case demonstrates the challenges in diagnosing vertebral osteomyelitis and provides relevant information for other physicians dealing with possible cases of vertebral osteomyelitis. CASE REPORT: An 83-year-old man presented to the Emergency Department with severe low back pain of 2 weeks’ duration. He had experienced occasional pain for several years, which was diagnosed as a compression fracture by an orthopedic surgeon at a local clinic. On arrival, he had a high-grade fever (40.2°C). The initial diagnosis was urinary tract infection, based on urinalysis results. However, after admission, vertebral osteomyelitis was diagnosed based on the results of magnetic resonance imaging of the spine and blood and urine cultures (both yielded methicillin-sensitive Staphylococcus aureus). He was immediately treated with the appropriate antibiotics and discharged on the 92(nd) day of admission without complications. CONCLUSIONS: Our report highlights the difficulties in clinical diagnosis of vertebral osteomyelitis and identifies factors that can affect the diagnosis, including clinician bias, search satisficing, premature closure, anchoring bias, and diagnostic momentum. All patients with low back pain should be considered potential candidates for vertebral osteomyelitis.