Fig. 18

Hindsight bias. A 40-year-old female patient with no known disease history presented at the ER with complaints of chest pain, dyspnea and confusion. As severe back and neck pain had been ongoing for two days, aortic dissection was suspected. Triple rule-out CT showed bilateral massive pleural effusion (a, d) and severe contrast reflux into the inferior vena cava, right renal vein (red arrows, b), and peripheral branches of hepatic veins (blue arrows, b). These findings were suggestive of hemodynamic compromise. Pleural effusions were drained, and a significant amount of pus was observed. The patient was accepted as septic, and proper treatment was started. Microbiological evaluation of the pleural fluid was consistent with Streptococcus pyogenes, an unexpected pathogen bacteria in pleural samples. After feedback from the microbiologist, an ecchymotic area spreading from the neck to the anterior chest wall was noticed. Soft tissue infection was suspected. When the CT was retrospectively re-evaluated, it was understood that increased densities in subcutaneous fat tissues of the neck and anterior chest wall (red circles c, d) were not noticed by the on-call radiologist ( purple arrows c, d: normal fat tissue as a reference). Lymphadenopathies within the affected areas (green arrows, c), and obliteration of upper mediastinal fat tissues (yellow circle, d) were other considerable findings. Moreover, mediastinal widening suggesting mediastinitis was detected retrospectively on the chest X-ray obtained after thoracentesis (yellow arrows, e). Subsequently, the clinical situation rapidly deteriorated, the patient became hypotensive and a sharp myoglobin increase suggesting myonecrosis was observed. Acute kidney failure, acute respiratory distress and profound thrombocytopenia developed. After evaluating the clinical, radiological and microbiological findings altogether, the diagnosis of “streptococcal toxic shock” was made. The patient died three days after the onset of the complaints and one day after ER admission. With the knowledge of S.pyogenes presence in the pleura, history of neck pain and location of the ecchymotic area, it seems impossible to have overlooked changes in soft tissues and the upper mediastinum during retrospective evaluation (hindsight bias)