Failure to diagnose tuberculosis

Presentation

A two-year-old boy with a five-day history of intermittent fever and stomachache was brought to his pediatrician. The child was diagnosed with a viral syndrome and treated with simethicone drops, liquid electrolyte replacement, and ibuprofen.

Physician action

Six days later – on July 16 – the patient was taken to the ED at a local hospital with continued fever, vomiting, wheezing, and shallow respirations. A chest x-ray was taken and interpreted by Radiologist A as “diffuse moderate perihilar interstitial prominence. Focal consolidation lateral segment right middle lobe and follow-up for pneumonia.” The child was diagnosed with an upper respiratory infection, prescribed amoxicillin, and discharged. The mother was instructed to follow up with their pediatrician.

Over the next few days, the child continued with fever and poor appetite. A neurologic assessment showed a slight deviation of the child’s right eye. Pediatrician A ordered a stat MRI that revealed “diffuse ring enhancing lesions in bilateral cerebral and cerebellar hemispheres.”

The following day, Pediatrician B admitted the patient to the hospital for possible meningitis. Another chest x-ray was taken and compared with the film taken four days earlier. It showed persistent right middle lobe consolidation but slight improvement of the interstitial prominence. The patient was transferred to a children’s hospital.

Pediatric Intensivist A treated the patient. The physical exam revealed the patient had altered mental status and a mild inward deviation of the left eye without any ocular lesions. An MRI revealed “multiple cerebral lesions with ring enhancements.” Pediatric Intensivist A’s impression was the child had probable neurocysticercosis. The differential diagnosis listed multiple abscesses and lymphoma with a secondary diagnosis of hyponatremia due to an inability to secrete ADH.

The patient was prescribed decadron and albendazole. An infectious disease specialist and pediatric neurologist were consulted. Results of a lumbar puncture were negative and the child was transferred to the pediatric ICU.

Pediatric Neurologist A assessed the patient the next day. His examination revealed mild nuchal rigidity. After reviewing the chest x-ray taken at the first hospital, Neurologist A questioned whether the film actually showed “perihilar adenopathy” — a finding generally consistent with tuberculosis in children. He ultimately concurred with the diagnosis of neurocysticercosis.

Radiologist B reviewed the previous chest x-rays and his impression was “right upper and right middle lobe infiltrate/atelectasis, interval improvement from prior study.”

The pediatric infectious disease physician’s impression was also neurocysticercosis. He mentioned that the family traveled frequently to Mexico, but there was no family history of tuberculosis or contact with tuberculosis.

Radiologist C read x-rays taken the following day, July 19. His interpretation was “frontal and lateral views of the chest again show a right middle lobe area of atelectasis and infiltrate with associated atelectasis and/or infiltrate of the right upper lobe in its apical segment. The heart is normal. There is no pleural effusion or pneumothorax.” His impression was no significant change.

Radiologist C also read the chest film taken from the prior hospitalization and mentioned that TB should be considered. However, he did not dictate his report until 3 days later and authenticated it 11 days later.

On July 24, the child became unresponsive. He developed fever and hyponatremia. EEG results suggested encephalopathy. A head CT noted brain edema in the right frontal lobe and left thalamus. A chest CT noted unusual vegetation at the junction of the superior vena cava and right atrium. The following morning, Pediatric Intensivist B reviewed the chest x-ray from July 24 that showed “hilar adenopathy and right middle lobe process.” He questioned whether tuberculosis could play a role in the patient’s condition.

Pediatric Neurologist A ordered a repeat MRI that showed findings consistent with multiple tuberculoma and tuberculous meningitis. Results of acid-fast stains of gastric aspirate confirmed mycobacterium tuberculosis. By the time the diagnosis was made, the patient had developed severe cognitive deficits that led to permanent disability.

Allegations

A lawsuit was filed against three pediatric neurologists, two pediatric intensivists, three radiologists, and the children’s hospital. It was alleged that all three radiologists misread the chest x-rays and failed to consider tuberculosis as a possible diagnosis. The plaintiff’s allegations focused on Radiologist C and included: failure to immediately notify the attending physician of the potential diagnosis of tuberculosis and failure to timely approve the report electronically.

Legal implications

Two defense reviewers stated that tuberculosis should have been high on the list of differential diagnoses based on the clinical presentation and geographical area. A blind radiology review confirmed that tuberculosis should have been listed as a differential diagnosis based on the x-rays on July 11 and July 19. However, because of the number of defense experts involved, there were some inconsistencies in their opinions.

The three-day delay in dictating the radiology reports on July 11 and July 19 created a significant weakness for the defense. Radiologist C failed to mention the possibility of tuberculosis due to the suspected lymphadenopathy on the July 11 report.

The plaintiff ’s attorney retained well-credentialed experts, who stated that the clinical presentation of the patient, along with lymphadenopathy on the various chest x-rays, should have made all the physicians suspicious for tuberculosis.

Disposition

Due to the sympathetic nature of the case, the potential for a high damage award, and the inconsistencies in the testimonies of the defendants, this case was settled on behalf of all defendants.

Risk management considerations

Radiologist C was working as a temporary employee and used the hospital’s PACS system, which was similar to the system that he used in his practice. He mistakenly concluded that when he used voice dictation to produce his report, the report would automatically be available for others to view. Radiologist C was unsure what “authenticated” meant. In this system, the report needed to be finalized to generate a report that other physicians could view.

Whether reading x-rays at multiple sites as a locum tenens or a temporary employee, thorough training on the facility’s PACS system is crucial. Although there are similarities, some PACS systems use different methods to finalize and transmit reports.

Additionally, reports should be reviewed for accuracy. Radiologist C read the first chest x-ray as “right middle lobe area of atelectasis and infiltrate without associated atelectasis and/or infiltrate of the right upper lobe in its apical segment.” Later he admitted that he was only aware that this patient had “right middle lobe infiltrate” and that this was a typo. It is important to review and dictate the patient history, which includes all previous diagnostic studies, especially when the films represent a pattern of serious ongoing problems.