Unusual clinical course Background:Human papilloma virus is a ubiquitous and preventable disease with the potential to cause recurrent respiratory papillomatosis. These papillomas affect the mucosal surface of the airways and may lead to airway obstruction. The papillomas require excision when breathing is compromised, and may be fatal if untreated. Rarely, these papillomas progress to cancer. Case Report:We report the case of a 21-year-old woman with a history of HPV 11-and 16-positive recurrent laryngeal and respiratory papillomatosis (RRP) since the age of 7 months, requiring multiple local resections in her respiratory tract. Chest CT demonstrated multiple cavitary lesions throughout both lungs with a rapidly growing mass that occupied most of her right lung. Imaging supported a diagnosis of malignant transformation to squamous cell carcinoma of the lung. Bilateral involvement of the lungs indicated stage IVa squamous cell lung cancer, which is not curable. Conclusions:Clinicians should suspect malignant transformation in patients with HPV type 11, especially if they have required multiple excisions. Earlier age at onset and number of excisions may be predictors for severity of the disease course. These patients need continued surveillance imaging to allow early interventions if malignant transformation occurs. We present the case of a 21-year-old being diagnosed with an incurable disease that may have been avoided with adequate preventive care.
Implicit (i.e., unconscious) bias frequently differs from one's explicit or conscious convictions. As humans, we rely on information and experiences that are repeatedly reinforced until they become reflexive, shaping our perceptions of reality. Specialty bias, a form of implicit bias specific to an individual's medical specialty, is a form of this bias. These cognitive processes of making assumptions aid efficient decision-making and likely confers an evolutionary advantage. However, automatic thinking can contribute to stereotyping, prejudice, and discrimination at both explicit and implicit levels. Despite a person's explicit beliefs evolving, the lasting implicit bias significantly impacts their behavioral interactions with individuals from stereotyped groups.We present a case of an 83-year-old non-English speaking gentleman with a reported past medical history of an ischemic stroke who presented with acute encephalopathy and fever without jaundice and Aspartate transaminase/ Alanine transaminase (AST/ALT) of 64 and 34, respectively. He was initially treated for acute meningoencephalitis in the Neurologic Intensive Care Unit. With no clinical improvement in symptoms, his care was transferred to the Internal Medicine service later that week, and it was noted that he had features consistent with liver disease. Further history-taking revealed that the patient was intermittently confused with episodes of constipation. On examination, he had palmar erythema and asterixis, and additional labs showed elevated liver enzymes and ammonia levels. Computerized Tomography of the abdomen was suggestive of cirrhosis. He was treated for hepatic encephalopathy with lactulose and rifampin, with improvement in his mental status.We believe our patient's clinical diagnosis was compromised by incomplete information related to a language barrier, and anchoring biases prevented a thorough history taking from the patient family and later on from the patient. Physician's anchoring bias, a form of implicit bias, can negatively impact outcomes in patients, especially those with limited language proficiency, due to communication barriers leading to misunderstanding of the patient's clinical presentation and overreliance on clinical heuristics.
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