Failure to diagnose necrotizing fasciitis

Presentation

On Saturday, September 13, a 47-year-old man came to an internal medicine physician’s office with complaints of “shingles since Wednesday on lower leg.”

Physician action

The internal medicine (IM) physician examined the patient and noted “severe redness lesion.” He gave the patient an injection of methylprednisolone and prescribed acyclovir and naproxen. The physician told the patient to return to the office or go to the emergency department (ED) if his condition became worse.

On September 15, the patient’s wife called the IM physician’s office and reported that her husband was still in pain. She also said she was worried about infection. The internist prescribed amoxicillin and hydrocodone/ibuprofen, and told her to take her husband to the ED if his condition worsened.

The next day, the patient came to the ED of a local hospital with swelling and blisters on his left leg. The emergency medicine physician noted the patient reported a 4- to 5-day history of leg swelling which began with blister-like lesions on the ankles.

The patient had seen his primary care physician who diagnosed shingles. The swelling was worse and now affected most of his lower left leg. Lab tests revealed a very high white blood cell count, elevated liver function, and acute kidney failure.

The emergency medicine physician diagnosed necrotizing fasciitis. The patient underwent emergency debridement of the wound. He remained hospitalized for six weeks and underwent nine debridement and skin graft procedures. He made a good recovery, but walks with a limp.

Allegations

A lawsuit was filed against the internal medicine physician. The plaintiffs alleged he breached the standard of care by failing to diagnose necrotizing fasciitis; misdiagnosing the patient with shingles; and failing to perform tests and studies to properly diagnose the patient’s condition.

Legal implications

Among the allegations, the plaintiffs claimed that if the patient had been directed to the ED on that Saturday (when he first visited the internist), he would have required less treatment and would have had a better result. However, the plaintiff’s own infectious disease expert testified that he did not know what difference earlier diagnosis could have made.

The patient testified that after he saw the internist, he “de-roofed” and drained the lesion. He then treated it with a homemade herbal remedy. The defense argued that the patient did have a shingles outbreak when he saw the IM physician, but then developed necrotizing fasciitis as a secondary infection before he went to the ED.

Disposition

This case was taken to trial, and the jury reached a verdict in favor of the IM physician.

Risk management considerations

The outcome of this case was a success for the defendant; however, this case offers an opportunity to comment on practice protocols and documentation that could be improved.

Two physicians who reviewed this case for the defense were critical of the documentation of the patient encounter. There was a lack of information about the patient’s illness and the exact location of the rash. The patient’s vital signs and the results of the physical exam were not documented.

One of the defense experts reported that he had not seen shingles or herpes zoster involve just one leg. He felt a bacterial infection could have been considered. When a diagnosis may not be straightforward, a differential diagnosis can be noted and either confirmed or ruled out. This allows for an explanation of the physician’s thought processes to be documented and offers rationale for the diagnosis.

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