The nurse practitioner claimed that she suggested that the patient could stop by the hospital for a blood test before leaving on vacation, but the patient denied that the nurse made the suggestion, and no notes supported the claim. The oral antibiotics relieved the patient’s symptoms only temporarily. The family cut short their vacation so the patient could return to the clinic, where she received another ineffectual antibiotic. When her condition continued to deteriorate, her husband took her to the ED of a larger hospital in the area.
The ED physician diagnosed subacute endocarditis, which was confirmed by subsequent tests. Testing also identified a bicuspid aortic valve, which increased the patient’s susceptibility to endocarditis. She was started on appropriate intravenous antibiotics and improved initially.
The patient subsequently noticed red patches on her hand and forearm. She also experienced problems with mental processing. She returned to the hospital, where a scan showed increased vegetative growth on her aortic valve. Pieces of the growth were breaking off, causing embolic injury to the patient’s brain, hand, and other areas of her body. The patient underwent open heart surgery to replace the aortic valve and prevent further embolic injury. She continues to suffer from significant short-term memory loss and will require warfarin for the rest of her life to prevent blood clotting.
PLAINTIFF’S CLAIM The patient should have been referred earlier for a complete workup, and the nurse practitioner should have taken seriously the culture showing S veridans. The nurse practitioner was mistaken in thinking that S veridans was found on the skin. Had she looked it up, which she should have done, she would have discovered that the organism is the most common bacterial cause of subacute endocarditis.
The patient had the classic symptoms of subacute endocarditis. The delay in diagnosis allowed bacteria to build up on her aortic valve, forming a biofilm barrier that inhibited the effect of the IV antibiotics and the body’s natural defenses and precipitated the embolic injury.
THE DEFENSE The patient was responsible for the delay in diagnosis, especially in light of the fact that she had a nursing background. Any negligence on the part of the nurse practitioner had no effect on the outcome.
VERDICT $1 million Washington settlement.
COMMENT Subacute bacterial endocarditis remains a challenging diagnosis with potentially devastating consequences. Be on the alert for this subtle masquerader.