Medical Malpractice Insights: Cryptococcal Meningoencephalitis

Author: Chuck Pilcher, MD FACEP (Editor, Med Mal Insights) // Editors: Alex Koyfman, MD (@EMHighAK) and Brit Long, MD (@long_brit)

Welcome back to Medical Malpractice Insights – Learning from Lawsuits, a monthly email newsletter for ED physicians, looks at a challenging diagnosis in a patient with no known risk factors for the disease. The goal of MMI-LFL is to improve patient safety, educate physicians, and reduce the cost and stress of medical malpractice lawsuits. To opt in to the free subscriber list, click here.

This month’s case looks at a challenging diagnosis in a patient with no known risk factors for the disease.

Chuck Pilcher, MD, FACEP

Editor, Med Mal Insights


Cryptococcal meningoencephalitis (CME)

Often overlooked cause of prolonged neuro symptoms – diagnose CME and become a hero

Facts: A 43-year-old woman presents to the ED with a recurrent headache and URI symptoms for 1 week. The workup is unremarkable. Her pain is controlled with ketorolac and droperidol, and she is discharged pain free. She returns 3 days later by EMS with headache, sleepiness, and +/- numbness in her hands. She again responds to non-narcotic treatment and is discharged. She is seen again in the same ED 16, 21, and 31 days after the second visit, each time with subtle symptoms of fatigue, photophobia, sleepiness, diplopia, mild neck and back pain, dizziness, arm pain, depression, etc. She remains afebrile with mildly elevated WBC, and a head CT is normal. On each visit she responds well to non-narcotic treatment and IV fluids. All visits are well-documented with appropriate medical decision making. On day 46 of her illness, she presents to a second hospital unable to walk and is admitted. She again improves. While awaiting discharge on hospital day 2, an MRI report notes subtle abnormalities in her meninges. An LP is done, resulting in the diagnosis of CME. She remains in the hospital for another 38 days. On discharge she has cognitive deficits severe enough to require long term assistance with ADL’s. She and her family seek legal counsel.

Plaintiff: You should have made the diagnosis sooner. If you had, I would not be disabled.

Defense: You had very non-specific symptoms. You always got better. Everyone was diligent in trying to learn what was wrong with you. CME is an indolent disease with occult symptoms and is rarely diagnosed early. Our medical decision making was well-documented throughout.

Result: An expert medical reviewer determined that the patient’s disease process was typical of many, if not most, cases of CME. No lawsuit was filed.

Takeaways:

  • CME is almost always missed early, often for several months.
  • While an earlier MRI and LP might have been indicated, a better outcome is not assured.
  • Defendants would have ample evidence in the record to sway a jury in their favor – at least in this case.
  • CME is similar to spinal epidural abscess in that both have many opportunities to be discovered early – if one considers the dx.
  • When faced with repeated visits for increasing and atypical neurological symptoms including headache, add CME to the differential.
  • An LP is the test of choice, but doing one early requires a high index of suspicion.

Reference: Cryptococcosis – Clinical Presentation. King JW. Medscape eMedicine. Updated Sep 11, 2018 

If we are supposed to learn from our mistakes, I should be a genius by now.

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