Treatment Injury

Delay or failure in diagnosing meningitis

In this case study we give an overview of 'Delay or failure in diagnosing meningitis' and feature expert commentary on how similar injuries might be avoided.

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Event: Delay/failure in diagnosis
Injury: Death

Key Points

  • Acute bacterial meningitis can develop fulminantly or it can develop progressively over several days preceded by a febrile illness, depending on the host’s response to the infection
  • Have a high degree of suspicion for meningitis when there is a febrile illness
  • Do not rely on classic physical signs and symptoms to rule out meningitis, as they are often absent
  • A low threshold for performing lumbar puncture is a prudent strategy
  • Antibiotics and dexamethasone must be started immediately if the diagnosis is being considered.

Case Study

Alan, a normally healthy 17-year-old construction apprentice, went to his general practitioner (GP) with a headache and shivering after being unwell for 24 hours.

When examined by the GP, Alan was found to have a temperature of 38.8˚C, a heart rate of 120/min, and a respiratory rate of 32/min. Alan appeared unwell but had an unremarkable examination. The doctor’s note commented that “Alan had difficulty in expressing himself”. The GP diagnosed Alan with a sinus infection. The GP prescribed Augmentin and paracetamol and gave Alan advice about meningitis, and suggested he needed to attend an emergency department (ED) if he had any further concerns.

That night Alan was unable to sleep. He continued to complain of a headache, became lethargic and began to vomit. This prompted Alan’s mother to take him to the local ED.

Alan was assessed at the ED, where blood tests were taken and he was started on anti-emetic treatment and fluids. The white blood cell count was slightly elevated and his physical examination was still unremarkable. Alan’s temperature was 37.8˚C and he was somewhat lethargic but easily arousable. A diagnosis of meningitis was considered and dismissed because he did not have all the classic triad of neck stiffness, fever and altered mental status. He was observed for several hours and then discharged home when his condition improved.

Alan deteriorated that afternoon and then became unarousable. He was immediately transferred to the ED by ambulance, where he was taken straight to the resuscitation room. He remained unarousable, his temperature was 38.3˚C, blood pressure 80/60, heart rate 130/min, respiratory rate 30/min and oxygen saturation 92%. Two petechiae (small areas of bleeding in the skin) were noted on his anterior chest. Unfortunately he continued to deteriorate and he was pronounced dead after significant efforts to resuscitate him.

A treatment injury claim was lodged by Alan’s GP for a failure to perform a lumbar puncture by the ED, which led to a delay/failure in diagnosing meningitis infection, which might have caused Alan’s death. ACC sought external clinical advice, which suggested that there had been a failure to perform a lumbar puncture, which led to the delay/failure in diagnosis. Based on this, the claim was accepted and funeral costs were covered by ACC. (No other compensation was payable as Alan did not have any dependants.)

Expert Commentary

Neil Waldman, FACEM
Acute bacterial meningitis has two classic patterns of presentation. It can develop fulminantly or it can develop progressively over several days preceded by a febrile illness, depending on the host’s response to the infection. A 2004 review showed that the classic triad of fever, neck stiffness and altered mental status is present in only 44% of adults and it is found in even fewer children. Physical signs early in the course may be subtle or lacking. Fever is found in 77-85% of cases and most have high fever, but a small percentage have hypothermia. A subacute presentation is found in 75% of children with evolution over two to five days. Adults average four consecutive days of fever. Neck stiffness is reportedly found in 83-94% of adults and signs of meningeal irritation are found in only 60-80% of children. A well designed prospective study in 2002 showed that nuchal rigidity and the classic Kernigs and Brudzinski signs are only 30% sensitive early in the course of meningitis, when there are few white cells in the cerebrospinal fluid (CSF). Headache is found in 79-94% of cases and altered mental status in 83% of cases. Most adults are confused or simply lethargic. Irritability or lethargy is found in 78% of children. A rash is only found in 11-26% of patients. Routine blood work is often unrevealing. The white blood cell count is usually elevated; however, severe infection can be associated with a low white blood cell count.

Every patient suspected of having meningitis should have a lumbar puncture unless contraindicated. Getting a CT scan prior to performing the lumbar puncture is not necessary in the majority of patients, and only for patients at risk for a mass lesion or increased intracranial pressure. It is imperative not to delay antibiotic administration until a lumbar puncture can be performed, and delay is an independent risk factor for mortality. Antibiotics should be started prior to sending patients to the CT scanner in cases of suspected meningitis. Fulminant cases should have the antibiotics started even before any lumbar puncture attempts. Prior administration of antibiotics has minimal effects on CSF chemistry and cytology, and pathogens can still be cultured from CSF or blood cultures. Dexamethasone is also indicated in all cases of suspected bacterial meningitis in adults and children when the pathogen is unknown. Dexamethasone should be started shortly before or at the same time as the antibiotics.

The major causes of bacterial meningitis in developed countries are Streptococcus pneumoniae and Neisseria meningitidis, and Listeria monocytogenes in patients older than 50. Broad-spectrum antibiotics are directed at these organisms until CSF gram stains or cultures identify the pathogen.

References/Websites

  1. UpToDate – online medical resource: “Clinical features and diagnosis of acute bacterial meningitis in adults” Tunkel, A. 3 July 2012.
  2. UpToDate – online medical resource: “Clinical features and diagnosis of acute bacterial meningitis in children older than one month” Kaplan, S. 27 August 2013.
  3. Marx-Rosen’s textbook of emergency medicine – Mosby 2009, Chapter 109, “Central nervous system infections” Meurer, W.
  4. Marx-Rosen’s textbook of emergency medicine – Mosby 2009, Chapter 175, “Neurologic disorders” Rubin, D.
  5. UpToDate – online medical resource: “Dexamethasone to prevent neurologic complications of bacterial meningitis in adults” Sexton, D. 24 July 2013.
  6. UpToDate – online medical resource: “Initial therapy and prognosis of bacterial meningitis in adults” Tunkel, A. 5 July 2012.
  7. Blue Book, 14th edition, Canterbury District Health Board, “Initial management of acute bacterial meningitis” December 2011.

Claims information

Between July 2005 and September 2013 ACC received 675 claims relating to delay/failure in diagnosing a condition. Of these, 257 were accepted and 418 were declined. Of the accepted claims, 51 were related to fatality due to delay/failure in diagnosing.

The most common reason for declining the claims was that no injury was identified due to the delay/failure and there was no causal link between the claimed injury and the delay/failure in diagnosis.

About this case study

This case study is based on information amalgamated from a number of claims. The name given to the patient is therefore not a real one.

The case studies are produced by ACC’s Treatment Injury Centre, to provide health professionals with:

  • an overview of the factors leading to treatment injury
  • expert commentary on how similar injuries might be avoided in the future.

The case studies are not intended as a guide to treatment injury cover.

Send your feedback to: TI.info@acc.co.nz

How ACC can help your patients following treatment injury

Many patients may not require assistance following their treatment injury.

However, for those who need help and have an accepted ACC claim, a range of assistance is available, depending on the specific nature of the injury and the person’s circumstances. Help may include things like:

  • contributions towards treatment costs
  • weekly compensation for lost income (if there’s an inability to work because of the injury)
  • help at home, with things like housekeeping and childcare.

No help can be given until a claim is accepted, so it’s important to lodge a claim for a treatment injury as soon as possible after the incident, with relevant clinical information attached. This will ensure ACC is able to investigate, make a decision and, if covered, help your patient with their recovery.

Downloads

Delay failure in diagnosis – November 2013 treatment injury case study

December 2013 Newsletter

Published 09/12/2013

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