Stubborn pneumonia turns out to be cancer
AFTER RECEIVING ANTIBIOTICS FOR PNEUMONIA, a 37-year-old man improved but didn’t fully recover; his radiographs didn’t return to normal. He’d never smoked cigarettes.
During the several months after the pneumonia, the patient’s doctor ordered repeat radiographs and prescribed antibiotics and pain medication. When the patient’s spine collapsed, the doctor diagnosed metastatic lung cancer. The patient received palliative treatment and ultimately died.
PLAINTIFF’S CLAIM The doctor was negligent in failing to change the patient’s treatment after 2 or 3 months and failing to order a computed tomography (CT) scan or refer the patient to a pulmonologist.
THE DEFENSE No information about the doctor’s defense is available.
VERDICT $1.25 million Washington settlement.
COMMENT I’d like a nickel for every case of delayed diagnosis of lung cancer based on clearly abnormal chest radiographs. We can argue about whether diagnosis would make a difference, but we need to follow up assiduously on abnormal radiographs and document our actions.
Rapidly raised serum sodium leads to osmotic demyelination
A 60-YEAR-OLD WOMAN went to her local medical center complaining of a cough for the previous 2 weeks, decreased appetite and oral intake, and generalized body aches. She first went to urgent care, where laboratory studies showed critically low levels of sodium and potassium. Based on these results, the woman was told to go to the facility’s emergency department (ED).
In the ED, she reported feeling very weak and tired and having body aches and pain. When laboratory tests showed that her sodium and potassium levels had fallen further, she was admitted to the intensive care unit (ICU).
The doctor who saw the patient in the ICU ordered intravenous fluids with normal saline and potassium supplements. He then had the patient admitted to the ICU at another hospital. The physician at that hospital continued to prescribe IV sodium and potassium until the patient was discharged with diagnoses that included hyponatremia and hypokalemia.
Ten days later, the patient returned to the ED complaining of slurred speech for the previous 2 days. A CT scan of her head showed a possible basilar tip aneurysm. Subsequent magnetic resonance imaging with and without contrast and intracranial magnetic resonance angiography confirmed a basilar tip aneurysm and showed findings suggestive of osmotic demyelination. Neurologic examination revealed dysarthria, right upper extremity weakness without spasticity, and periods of confusion interspersed with lucid intervals.
A subsequent neurologic consultation confirmed osmotic demyelination syndrome (formerly known as central pontine myelinolysis). Neurologic examination at that time found continued mild dysarthria, problems standing, inability to walk unsupported, mild oral and pharyngeal dysphagia, and language and writing deficits.
PLAINTIFF’S CLAIM The patient’s sodium level was increased at an inappropriately rapid rate, which caused neurologically devastating osmotic demyelination. Serum sodium should have been monitored every 4 hours during the first 24 hours of treatment. The plaintiff also alleged negligence in continuing normal saline after the patient’s serum sodium was measured at 112 mEq/L.
THE DEFENSE The treatment provided was appropriate.
VERDICT $550,000 California settlement.
COMMENT Avoiding osmotic demyelination syndrome requires careful treatment and monitoring. I have independently reviewed several allegations of malpractice involving this uncommon, but devastating condition. Two recent articles summarize the treatment of this disorder: Sterns RH, Silver S, Klein-schmidt-DeMasters BK, et al. Current perspectives in the management of hyponatremia: prevention of CPM. Expert Rev Neurother. 2007;7:1791-1797; and Lien YH, Shapiro JI. Hyponatremia: clinical diagnosis and management. Am J Med. 2007;120:653-658.