Avoiding Cognitive Bias in Radiology: New Brain Lesions in Homeopathically Treated Breast Cancer Patient

Cognitive biases can impact diagnostic accuracy and timeliness of medical care.Crucially, these biases can be mitigated by carefully integrating clinical data.Herein, we present a case of a patient with metastatic breast cancer treated with homeopathic therapy, who presented with new hyperdense non-enhancing brain lesions on CT.This case highlights the risks of framing bias for radiologists when little clinical information is available and underscores the necessity of a thorough evaluation and review of clinical history to identify alternative diagnoses and ensure timely and accurate management.It also highlights the expected imaging appearance of treated versus untreated intracranial breast cancer metastases.An adult female patient with ERþ/HER2-invasive breast ductal carcinoma with chest wall and spine metastases presented with acute delirium several weeks after posterior spine decompression surgery for cord compression due to epidural metastasis.Thus far, she had been treated with homeopathic remedies without a conventional chemotherapy regimen.Her postoperative course was complicated by mildly decreased sodium level likely in the context of the syndrome of inappropriate antidiuretic hormone secretion and dehiscence of the surgical wound, for which she was followed by a wound care nurse.Approximately two weeks after the surgery, she became acutely confused and disoriented in a setting of still mildly decreased sodium level, a positive urinalysis and mild fever.Unenhanced CT brain performed in the emergency department showed multiple intra-axial hyperattenuating foci (Figure 1a), initially appropriately considered hemorrhagic metastases without differential considerations.Radiation oncology was consulted to manage further care.A subsequent gadoliniumenhanced MRI head showed multiple intraparenchymal foci of susceptibility without enhancement (Figure 1b,c) that were first considered metastases but then also prompted consideration of septic emboli as an alternative diagnosis since untreated breast cancer metastases should enhance.The radiology report triggered an infectious disease consult and a workup for a potential infectious source.Urine and blood cultures grew Staphylococcus aureus.MRI of the spine showed expected postoperative findings without evidence of abscess.A transesophageal echocardiogram then revealed the presence of mitral valve vegetation that was later

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