Failure to diagnose bacterial endocarditis

Presentation

A 33-year-old woman came to her family physician reporting severe sacroiliac pain that radiated down into her left knee for one week. The patient was six weeks postpartum.

The patient’s ob-gyn had performed a cesarean delivery without any complication. The patient’s hospital course had been unremarkable, and she was discharged home on postoperative day three. Three weeks later, the patient followed up with her ob-gyn for a postpartum check. He noted the patient’s incision was well healed.

Physician action

The family physician found the left sacroiliac joint was tender and the patient unable to bear weight. The patient was diagnosed with acute low back pain, left sciatica, and left sacroiliitis. Diclofenac, hydrocodone, and heat were prescribed. A telephone message one week later noted, “leg is better, right leg-thigh, hip hurts when walking.” The patient was referred to an orthopedic surgeon.

Ten days later, the patient returned to the family physician with reports of back and leg pain. The left sciatica was improved, but was now present on the right side. The family physician’s assessment was right sciatica. She was prescribed methylprednisolone, diclofenac, carisoprodol, and hydrocodone, and instructed to follow up in two to three weeks.

An x-ray of the pelvis and lumbosacral spine showed degenerative arthritis and mild bilateral sacroiliitis. The family physician sent the patient’s information and x-ray report to an orthopedic surgeon.

Over the next several months, the patient continued to experience back and leg pain. She received treatment from a neurosurgeon, neurologist, and an orthopedic surgeon. X-rays and MRI showed no evidence of disc herniation and her hips appeared to be normal.

Approximately three months postpartum, the patient was admitted to a local hospital with fever, increased heart rate, abdominal pain, and shortness of breath. She was diagnosed with Enterococcus faecalis endocarditis of the aortic and mitral valves with congestive heart failure and enterococcal sepsis. A CT scan and ultrasound revealed a cystic mass on the spleen and a possible splenic abscess. A splenectomy was scheduled.

An infectious disease physician was consulted and noted, “Certainly, the C-section may be an important history, and perhaps this was the origin of the bacteremia ... enterococci are the most likely pathogens. Pneumococcus is considered as well given the fairly aggressive nature over the current process, but this is much less likely. Staphylococcus aureus is possible as well despite the preliminary morphology report.”

Antibiotic treatment was begun with vancomycin and gentamicin.The patient underwent an emergent aortic valve replacement, mitral valve replacement, intra-aortic balloon pump, temporary pacing wires, and evacuation of bilateral pleural effusion and pericardial effusion.

Two weeks later, she was diagnosed with a right femoral pseudoaneurysm and renal failure. A cardiovascular thoracic surgeon repaired the pseudoaneurysm and placed a left subclavian Hickman catheter assisted by fluoroscopy.

The patient was discharged four weeks later. She began rehabilitation that included physical and occupational therapy. The patient continues to follow up with an internal medicine physician and cardiologist.

Allegations

A lawsuit was filed against the family physician, alleging failure to diagnose and treat the patient’s bacterial endocarditis. A lawsuit was also filed against the ob-gyn.

Legal implications

The plaintiffs obtained expert support for their allegations. Specifically, their family physician expert testified that the defendant was negligent for not taking the patient’s temperature and not performing a urinalysis during the two visits. He also stated that it was inappropriate for the physician to prescribe steroids and they exacerbated the infection.

Defense family physician experts were supportive of the defendant’s actions. It was reasonable to ascribe the patient’s back pain to mechanical causes and there was no reason for the physician to suspect an infection.

According to the defendant’s records, the patient made no mention of fever, so her temperature was not recorded. Subsequent CBC and urinalysis performed after the family physician examined the patient were negative. The family physician made appropriate and timely referrals to specialists.

Disposition

This case was taken to trial and the jury returned a verdict in favor of the defendant. The case against the ob-gyn was dropped before trial.

Risk management considerations

The plaintiff’s expert testified that the defendant failed to meet the standard of care because he did not take the patient’s temperature. He argued that a patient’s temperature should be taken at every office visit. The family physician’s nurses testified that it was their standard practice to document reports of fever. Absent reports of fever or a specific reason to take a temperature, they do not take a temperature on every patient at every visit. Having this practice protocol in place, and ensuring staff followed it, likely helped the defendant in this case.

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