Case Archive
Infectious Diseases
Ref. # 421601

A veterinarian specializing in exotic fish and reptiles presented to the ER with pain and swelling in the left fourth finger. He was examined by a hand surgeon, who placed him on IV antibiotics and the next day performed surgery for pyogenic flexor tenosynovitis. The surgeon performed multiple debridements during the next week, after which the patient was seen by an infectious diseases specialist, who diagnosed ordinary pyogenic infection. The ID physician performed further debridement and placement of tobramycin beads. Two weeks later the finger continued to be problematic so the patient sought a second opinion at another medical center. An ID physician diagnosed mycrobacterium marinum infection. Treatment included minocycline, which cleared up the infection. The patient required more than ten surgeries to restore function to the finger. A medQuest ID expert reported that the failure to initially consider and culture for mycrobacterium marinum in light of the patient's history of exposure to fish and reptiles constituted negligence. Furthermore, there was a failure to appreciate the significance of negative bacterial cultures, as well as improper use of tobramycin beads without microbiologic diagnosis. With timely care and treatment the patient would have quickly regained normal use of the finger.

Infectious Diseases
Ref. # 78448

A middle-aged Ohio woman with exogenous obesity, insulin-dependent diabetes and prior history of hypertension was admitted to the ER and diagnosed with stress incontinence. She underwent endoscopic urologic surgery. She was treated with IV and oral antibiotic prophylaxis and discharged post-op day four, despite complaints of bladder pressure and inability to void at time of discharge. She was readmitted eleven days later with severe abdominal pain and required incision and draining of a suprapubic abscess with extension into the left groin, causing pyomyocitis. For the subsequent month treatment was incision and drainage of the abscess and IV antibiotics, without a wound culture despite serosanguinous drainage. The undiagnosed organism ultimately proved resistant to the IV antibiotics prescribed. A medQuest infectious disease specialist reported that cultures of the wound should have been obtained post-op in light of the patient's abnormally high white blood cell count, as well as the fact that diabetics are at increased risk for post-op infections. The one-month delay in the identification of the organism resulted in multiple debridements due to muscle necrosis, thigh abscess and involvement of the rectus muscle, all of which were avoidable with appropriate management.

Infectious Diseases
Ref. # 30338

A 37 year old Missouri man was admitted to the hospital for a fever of unknown origin, which had lasted approximately three weeks and was unresponsive to oral antibiotics. The patient had Hodgkin's lymphoma 17 years prior and a pacemaker placed two years prior for complete heart block. Blood cultures and an echocardiogram were concurrent with mitral valve leaflet thickening and regurgitation. The patient was started on IV antibiotics. The preliminary report of the blood culture was relayed as negative. The patient was transferred two days later to another hospital, where he was diagnosed with endocarditis with large vegetations noted on the aortic valve. The patient's course was further complicated by staph pneumonia, progressive hypoxemia, interstitial pulmonary edema, need for swan placement, and aortic valve replacement due to increased heart murmur and significant aortic incompetence. Fifteen days after the transfer, it was learned that the blood cultures at the first hospital were in fact positive for staph bacteremia. The operative course was complicated by the inability to control bleeding and the patient expired. Operative notes documented large vegetations compatible with partly treated endocarditis. A medQuest infectious disease specialist reported that the administering physicians at the second hospital made repeated inquiries to the lab and to the administering physicians at the first hospital as to the results of the blood cultures. Negligent lab procedures and failure to communicate the results led to almost three weeks of inappropriate treatment. Had the patient been appropriately treated upon transfer he more likely than not would have survived.

Infectious Diseases
Ref. # 56718

A 32 year old New Jersey woman presented to a Lyme Care Center, complaining of respiratory infection, fatigue, back pain, and libido problems. A Western Blot was concurrent with Lyme Disease. An ID expert specializing in Lyme Disease prescribed oral and IV antibiotics, including Amoxicillin and Zithromax. After six months of ongoing symptoms, the patient was referred to a neurologist, who prescribed anti-depressants. The ID specialist continued the antibiotics and the patient had a Hickman catheter inserted for IV Vancomycin. Four months later the antibiotics were discontinued and the catheter was left in place. The next month the patient complained of high fever and chills. The ID expert prescribed Plaquinil for apparent malaria. Four days later the patient had not improved and was sent to the hospital. After 12 more days the diagnosis was bacteremia from the catheter. A medQuest ID specialist reported the attending ID specialist negligently prescribed Vancomycin, which is inappropriate for Lyme Disease, and failed to remove the Hickman catheter upon antibiotics completion. The patient's infection was ignored for 16 days and blood cultures were not obtained. Her complications and pain and suffering were avoidable.

Infectious Diseases
Ref. # 78238

A 21 year old Missouri woman who had been breast feeding was admitted to the ER due to progressive right breast pain, fever, headache, photophobia, and mid-epigastric pain. Over a two-day period, she was described as ill-appearing, with a blood pressure of 100/50, pulse 124, and temperature 102.3. The upper outer quadrant of the right breast was tender. A lumbar puncture was unremarkable. A blood culture was ordered but the final result was never reported. Treatment that night included Demerol and Vistaril for pain. Four hours later she was difficult to arouse and noncommunicative. She was discharged and taken home, where she was found semi-conscious on the bathroom floor four hours later. She died shortly thereafter from sepsis due to acute mastitis. A medQuest infectious disease specialist opined that, in light of the patient's declining condition as noted by nurses at the hospital, her discharge without a re-examination constituted negligence. With appropriate treatment such as IV antibiotics and fluids, close monitoring of vital signs, and aggressive management of the sepsis, the patient would have survived.

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