Ascending Aortic Aneurysm [Endocarditis Misdiagnosis]
Case #161
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A 43-year-old man presented to the ED with general malaise, chest pain, upper and lower back pain, vomiting, and a left foot wound from stepping on an unknown object a few days earlier.
He was seen by an EM physician (Dr. B).
The vitals were normal.
The only noteworthy exam finding was a dark discoloration on the bottom of his left foot without surrounding erythema.
Exam was otherwise unremarkable, including no cardiac murmurs.
An EKG showed sinus rhythm with a rate of 76bpm and nonspecific T-wave abnormalities.
CXR showed “interstitial changes” suggestive of early pneumonia.
The foot x-ray showed a “possible radiopaque foreign body”.
A few noteworthy labs were mentioned in the court documents:
WBC count - 23.6 (neutrophils 84.7, lymphocytes 8.0)
Creatinine - 1.22
ESR and CRP were reportedly “markedly elevated”
Lactic acid - 2.7
Editor’s note: No troponins were listed anywhere in the court records. I suspect that they were checked and were negative, but have no proof of this.
Fluids, antibiotics, and pain medication were ordered.
The patient felt better.
The hospitalist (Dr. K) was consulted.
The only additional finding was that Dr. K heard a cardiac murmur during his examination.
In light of the murmur and labs suggestive of infection, both physicians were concerned for endocarditis.
The patient was started on Unasyn.
Overnight he needed an additional dose of morphine, but otherwise had an uneventful course.
The next morning around 8am, the patient had worsening chest pain.
A repeat EKG did not show any evidence of acute cardiac ischemia.
He developed hypoxia and appeared unwell.
A CTA of his chest/abd/pelvis was ordered.
The scan was done at 8:19am, and the report signed at 9:15am.
It showed an ascending aortic aneurysm 7.5cm in diameter, with active extravasation and mediastinal hematoma.
Vascular surgery was consulted, and recommended transfer to an academic medical center.
The patient was taken by ambulance to the helipad.
Unfortunately on the way to the helipad, he coded.
The ambulance returned to the ED.
Attempts at resuscitation were unsuccessful and the patient was declared dead.
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The patient’s wife contacted a law firm.
A lawsuit was filed against the ER physician (Dr. B) and the admitting hospitalist (Dr. K).
The following expert opinion was written by a hospitalist for the defense (Dr. Y).
The case went to a jury trial.
The jury returned a verdict for the plaintiff, finding both the ER doctor and hospitalist were negligent.
The patient’s wife and 2 young daughters were awarded $20,000,000.
The jury determined that a portion of the damages will be paid out to the patient’s daughters over the next 28 years. Per news reports, accumulated interest will add an additional estimated $9,000,000 to this amount.
MedMalReviewer Analysis:
One thing that makes this case confusing is the fact that the expert refers to an aortic dissection, while the radiology report he cites indicates a ruptured aortic aneurysm. A dissection and an aneurysm can coexist, but they are two different disease processes. They are not interchangeable terms. This is not the first medical malpractice case I’ve read in which it’s not entirely clear whether an aneurysm or a dissection killed the patient. The radiology report seems quite clear that it was an aneurysm, but the clinical presentation reads like a dissection.
I think it was very reasonable to assume that the patient had endocarditis. He had several potential sources of infection (foot foreign body, bacteriuria, pneumonia), a significant leukocytosis (23.2), elevated lactic acidosis, and a new cardiac murmur. The only thing that could potentially have tipped them off was the fact that the pain radiated to his back, but this was only a minor complaint amongst a constellation of various symptoms that muddied the clinical picture. I think the majority of clinicians would have arrived at the same conclusion and missed the aortic emergency.
I have 2 tangential criticisms in regards to their treatment of presumed endocarditis. First, there was reasonable concern that a foreign body in his foot was a source of infection. The fact that it was not removed (or at least explored to prove there wasn’t a foreign body) constitutes a failure to obtain source control. Secondly, Unasyn monotherapy was insufficient. The patient had a potential skin source and MRSA was a reasonable concern, not to mention the possibility of pseudomonas if the wound was a puncture through a rubber sole.One of the main points I take away from this case is that patients with severe chest pain coupled with unusual pain that radiates to numerous other areas should trigger concern for an aortic emergency. This patient had upper and lower back pain, jaw pain, and general body aches/myalgias. We all fall into the cognitive trap of thinking chest pain = cardiac ischemia, but the more the pain radiates to other areas and takes on unusual characteristics, the more worried we should be about the aorta. If you’re admitting a chest pain patient but they have an unusual constellation of additional symptoms, alarm bells should go off in your head. Unfortunately, this heuristic is not completely accurate, and the diagnosis is one of the most challenging we can make. Cardiac ischemia can also cause unusual radiating pain, especially in women. Even the most astute physicians can miss this diagnosis, and that doesn’t mean they fell below the standard of care.
This case was a good opportunity to review the utility of a neutrophil-to-lymphocyte ratio (NLR) in diagnosing aortic emergencies. I hadn’t read anything about this topic before but was intrigued by this meta-analysis, demonstrating higher NLR values in both aneurysm and dissection as compared to controls. They also found higher NLRs in patients who died from their aortic emergency, as opposed to patients who survived. This patient had an NLR of 10.6 (84.7 / 8.0), which is markedly elevated. The cutoffs for dichotomization in the meta-analysis ranged from 3.5 to 9.7.
Unfortunately, NLR isn’t a magical tool that we can use to diagnose a dissection or aneurysm. It’s elevated in numerous other conditions (particularly infectious causes, which is what they thought this patient had!), and widely associated with increased mortality. We’re all familiar with the relevance of a neutrophilic predominance, and the NLR seems to be derivative in some regards. However, the NLR may have some clinical utility and I’ll be interested to read more about it as more papers are published.
Another example of why medical malpractice cases should be tried by a jury of medical professionals.
Absolutely astonishing and horrifying to me that two physicians, who performed reasonable workups and were ambushed by an AAA they had no particular reason to suspect, are now liable for more money than they would likely make in their careers.