Osteopathy, Pediatric Neurology, Pediatric Endocrinology
Ref. # 544101
A 12 year-old boy with a history of hyponatremic dehydration one year prior presented to his osteopathic pediatrician. He complained of vomiting for two weeks, diarrhea, sore throat, headache, fatigue and black lines on the tongue. After examination the impression was acute appendicitis and the boy was admitted that day to an osteopathic hospital. An ER exam recorded the boy appeared pale, weak with poor skin turgor. White blood cell count was 10.4, hemoglobin 14.2. The boy was hypoglycemic, hyponatremic and hypochloremic. An EKG showed right bundle branch block, which was ruled out due to a normal QRS interval (measures ventricular activity). The boy was followed under pediatric medical management with the assessment of gastroenteritis, resolving dehydration hyponatremia, and asthma. Four days post-admittance a neurologist examined the patient and noted increased tone in the lower extremities: left foot greater than right, brisk deep tendon reflexes at the knees, bilateral foot drop, and a slow shuffling gait. A CT scan was normal. Differential diagnosis was Charcot-Marie Tooth disease vs. Friedrichs ataxia. After three days the boy was discharged with a referral to a neurological center, where he presented one week later. A neurologist there noted the primary symptom was pain in the feet with occasional burning in the hands. The boy was generally weak. The previously described abnormalities in muscle tone were no longer evident. The impression was peripheral neuropathy manifesting itself as dysesthesias. The boy was prescribed Elavil, 10 mg at bedtime. Two days later he was found at home in bed with agonal respirations. Paramedics arrived and found him in ventricular tachycardia. The boy was defibrillated three times and transported to the ER. On admission he was documented as having low serum cortisol in spite of a Solu-Cortef dosage en route. A consulting endocrinologist opined that adrenal insufficiency had to be considered. Two days later the boy suffered cardiac arrhythmia, hypotension and expired. The autopsy showed marked adrenal atrophy and acute hypoxic/hypoglycemic damage to the hippocampus, putamen and cerebral cortex. A medQuest osteopathic pediatrician reported a negligent failure to treat a grossly abnormal EKG and low sodium level of 114. A medQuest pediatric neurologist opined the cause of death was acute adrenal failure as manifested by hypovolemic shock, hyponatremia and hypoglycemia. Despite the boy's history of hyponatremic dehydration, there was a negligent failure to diagnose adrenal insufficiency and provide appropriate treatment with serum cortisols. No endocrine consult was ever secured as standard of care required at the osteopathic hospital. The initial neurologist inadequately documented the exam of the boy and negligently misdiagnosed Charcot-Marie Tooth and Friedrichs ataxia, which was not supported by symptomology nor followed up with appropriate imaging, electrical or metabolic studies. The negligent care led directly to the boy's death. A medQuest pediatric endocrinologist independently concurred that the boy's care was mismanaged even as his symptoms became acute. With appropriate care the boy would have survived.