Medical Malpractice Insights: Missed meningococcemia in the midst of a meningitis outbreak
- Dec 13th, 2022
- Chuck Pilcher
- categories:
Here’s another case from Medical Malpractice Insights – Learning from Lawsuits, a monthly email newsletter for ED physicians. 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. Stories of med mal lawsuits can save lives. If you have a story to share click here.
Chuck Pilcher, MD, FACEP
Editor, Medical Malpractice Insights
Missed meningococcemia in the midst of a meningitis outbreak
Would you have managed the patient differently?
Facts: During a meningitis outbreak at a major university, an 18-year-old African-American female college student athlete awakens with sore throat, chills, and lower back pain. On presentation to the ED shortly thereafter, her temperature is 39.6 C with rigors, severe large group muscle pain, and spasms. She is discharged 3 hours after arrival with a 
diagnosis of flu-like illness. She is found unconscious in her dorm room later the same day and is pronounced dead upon ambulance arrival at the hospital. Autopsy finds petechiae, and the cause of death is listed as disseminated (except in CNS) meningococcal disease. The CDC quickly mandates immunization of nearly 22,000 staff and students at the university. A lawsuit is filed.
Plaintiff: There was a known outbreak of meningitis at my university. I was the 4th person (of an eventual 7) in the epidemic. You yourself even treated one of them before me. Meningococcal disease begins with flu-like symptoms. You were focused on checking me for meningitis. Good for you, but you didn’t even think I might have meningococcemia. You didn’t complete a differential diagnosis and went down the wrong road. You didn’t do any blood tests or cultures, you didn’t prescribe antibiotics, and you discharged me with an incomplete evaluation. My death was preventable.
Defense: I checked for symptoms of meningitis – a meningococcal infection. You didn’t have a rash, altered mental status, or other signs of the disease. I even checked you for petechiae. Meningococcemia is rare. Your presentation was unusual, and your disease was unusually aggressive. I used clinical judgement and followed the standard of care. Your death was a tragedy, but it was not the result of medical negligence.
Result: Plaintiff verdict for $1.5 million after a 3-week trial and 6 hours of deliberation.
Takeaways:
- As always, don’t get hooked by anchoring bias. Keep an open mind. Our first impression may be right 90% of the time, but with serious illnesses, we can’t accept a 10% miss rate.
- Petechiae are best seen on the conjunctivae, soles, and palms of dark-skinned patients.
- Meningococcal infections present as meningococcemia 30-40% of the time and are frequently fatal. Think about that in the midst of an epidemic or outbreak.
- When in the midst of a well-publicized epidemic, hospitals and ED’s should develop a plan. In this case there were no specific plans for managing febrile, myalgic, suddenly sick college kids with or without meningeal signs. Who gets a CBC, blood culture, LP, empiric antibiotics, etc.? Make a plan.
- FYI, the six other patients survived after receiving medical treatment.
References:
- Clinical manifestations of meningococcal infection. Apicella, M. UpToDate Online. Updated 4 Oct 2021. https://www.uptodate.com/contents/clinical-manifestations-of-meningococcal-infection?
- Meningococcemia. Javid MH. Medscape eMedicine. Updated 5 Aug 2022.https://emedicine.medscape.com/article/221473-overview?pa=Tmu49UW1wTZTNd0vMNXSLK8pa8WxsQ47lbsY3My5h6pyIRymClzjUQEYql4nYvOoJyGvMX/u+WdIXoARf/T0zw==
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