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Legal Review & Commentary
Failure to diagnose child's bacterial infection leads to amputation: $3 million settlement
Radha V. Bachman, Esq.
Buchanan Ingersoll & Rooney PC
Lynn Rosenblatt, CRRN, LHRM
HealthSouth Sea Pines Rehabilitation Hospital
News: A child presents at a hospital emergency department (ED) complaining of a fever and rash. A physician's assistant employed by the hospital examined the child and described the rash in the child's chart. The child was discharged with instruction to see a pediatrician but with no guidance as to how to manage the fever. The child's symptoms became worse, and the child was eventually diagnosed with staph sepsis. The child required amputation of portions of both hands and both feet. A $3 million settlement was reached during mediation.
Background: The plaintiff, a 4-year-old girl, was seen in a hospital ED due to a developing fever and rash with pustules in her mouth. The ED nurse first documented "petical rash" in the plaintiff's chart, later replacing it "pustule rash." As opposed to petechial rashes, which cause red/purple spots that do not blanch on pressure, pustule rashes cause raised bumps on the skin filled with pus. Once triage was completed, the plaintiff was seen by a certified physician's assistant ("PA"). The plaintiff's temperature was taken, and it was discovered that she was suffering from a 103°F fever. The PA documented a "macular/papular rash" in the plaintiff's chart and did not further document the rash in the girl's mouth. In general, rashes may be described as macular (showing flat, red spots), papular (showing small, raised, solid bumps), or macular and papular (a combination of macules and papules). The parents provided further information to the PA by indicating that the plaintiff had brick-red skin and that they were able to write their names into her back by placing pressure on it with their fingers.
The plaintiff was eventually discharged with limited instructions from the PA to visit a pediatrician. The instructions carried with it no referrals of pediatricians in the area, time frames, or treatment suggestions for her ongoing fever. There also is no evidence that the plaintiff was seen by a physician while in the ED. The next day, the plaintiff's condition worsened, and the plaintiff's parents took her to another hospital ED. The subsequent hospital's ED transferred the patient to a third hospital, where she was diagnosed with staph sepsis. Sepsis is a bacterial blood infection that causes high fever, rapid heartbeat and breathing, weakness, dizziness and affected consciousness, and often arises from skin vascular catheters, infected intestine in extremely ill patients or those receiving long-term antibiotic treatment. Sepsis is often hard to diagnose and treat and may be life-threatening. Common symptoms of staph sepsis include: pain or swelling around a cut, or an area of skin that has been scraped; boils or other skin abscesses; blistering, peeling, or scaling of the skin (most common in infants and young children); and enlarged lymph nodes in the neck, armpits, or groin. Ultimately, the infection became worse and the plaintiff required amputation of portions of both feet and both hands. She was later fitted with prosthetics that gave her the ability to run and walk.
The plaintiff argued that the defendants, through its employed nurse and PA, had been negligent in failing to diagnose the bacterial infection during her first visit to the ED. She further accused that the PA had performed a deficient examination that failed to address the need for additional testing. The plaintiff believed that she should have been seen by a physician at some point during her visit and not solely by a PA.
The defendant contested plaintiff's allegation stating that the PA's examination and diagnosis of the plaintiff was proper based on the type of rash observed and the fact that it was consistent with a viral infection. The defendant further argued that the bacterial infection that later arose in the plaintiff is extremely rare and that the plaintiff's parents should have returned the girl to the defendant's ED for proper treatment.
The parties reach a settlement during mediation in the amount of $3 million.
What this case means to you: This child presented with what appears to be a classic case of a well-known childhood malady, scarlet fever. Given her symptoms, any health care practitioner familiar with the treatment of children should have been suspicious that this child had some form of bacterial infection. The fact that the ED staff at the first hospital missed this altogether speaks to the need to have triage professionals who have pediatric experience available to assess and treat children in hospital EDs. The ED staff providing emergency services to the community at large should, at the very least, be trained in one of the most common of childhood illnesses, streptococcal infection.
The rash is the most striking sign of scarlet fever. It usually begins appearing like a severe sunburn with tiny bumps that may cause itch. Areas of rash usually turn white when pressure is applied to them. The rash will usually appear initially on the neck and face and later spreads to the trunk, and then to the rest of the body. In body creases, especially around the underarms and elbows, the rash forms classic red streaks. The palms of the hands or soles of the feet are not affected and are pale in contrast to the "scarlet hue" of the outer skin surfaces.
Aside from the rash, there are usually other symptoms that help to confirm a diagnosis, including a reddened sore throat, and a fever above 101° F (38.3°C). The tonsils and back of the throat may be covered with a whitish coating, or appear red, swollen, and dotted with whitish or yellowish specks of pus. Early in the infection, the tongue may have a whitish or yellowish coating. A child with scarlet fever also may have chills, body aches, nausea, vomiting, and loss of appetite. Headache also is a frequent complaint. It is common for the child to first complain about a very sore throat that appears red to the eye, and the tongue often has a coated appearance. The child will have difficulty swallowing, as the lymph nodes of the neck are frequently swollen and tender to touch.
Group A beta-hemolytic Streptococcus, or Streptococcus pyogenes, causes scarlet fever. This is the same bacterial infection that causes strep throat, but the strain of bacteria causing scarlet fever releases toxins that produce the rash. Strep can spread from one person to another by fluids from the mouth and nose. In rare cases, scarlet fever may develop from a streptococcal skin infection such as impetigo. In those cases, the child may not experience a sore throat or related symptoms.
If a person infected with this bacterial infections coughs or sneezes, the bacteria can become airborne. Alternatively, the bacteria may be present on things the person touches, such as toys or other objects in a day care setting. If the child had been around other infected individuals, she may have inhaled the bacteria or may have touched something that was contaminated and then touched her own nose or mouth, thereby transmitting the bacteria. The incubation period of the bacteria usually is two to four days.
If scarlet fever is not treated, a person may be contagious for a few weeks even after the illness itself has passed. In rare cases, someone may carry scarlet fever strep bacteria without being sick. Therefore, it is difficult to know if you have been exposed. Strep bacteria also can contaminate food, especially milk, but this mode of transmission is not as common.
For those reasons, strep throat is the scourge of institutional settings where children congregate. Children 5 to 15 years of age are more likely than other people to get scarlet fever. The bacteria make a toxin that can cause the scarlet-colored rash, but not all streptococci bacteria make this toxin and not all kids are sensitive to it. Two kids in the same family may both have strep infections, but one child (who is sensitive to the toxin) may develop the rash of scarlet fever while the other may not.
More common complications that may result from untreated scarlet fever include bacterial infection of the blood or sepsis, otitis media, meningitis, endocarditis, pneumonia, pus-filled abscess in the throat, sinusitis, and skin infections, all of which are common in children and extremely contagious.
Scarlet fever rarely results in serious complications, but without proper treatment conditions such as rheumatic fever, an inflammatory disease that can affect the heart, joints, skin, and nervous system may occur. Long-term effects may include damage to heart valves and other heart disorders that were common before the advent of antibiotics. Appropriate treatment of strep bacteria infection greatly reduces the risk of rheumatic fever. Complications also can cause kidney damage, and some researchers believe strep bacteria infections are associated with an autoimmune disorder that significantly exacerbates psychiatric symptoms in children who have neuropsychiatric disorders.
Acute Streptococcus pyogenes infections also may present as a form of cellulitis, which is an infection of the deep layers of the skin. Invasive, toxigenic infections can result in necrotizing fasciitis, myositis, and streptococcal toxic shock syndrome. This is an extreme and rare presentation, but left untreated, Streptococcus pyogenes can be deadly.
Diagnosis is relatively straightforward, as this is a common illness among school-aged children. An exam to determine the condition of the child's throat, tonsils, and tongue is conducted. The neck is examined to determine if lymph nodes are enlarged. The appearance and texture of the skin rash is assessed. If your doctor suspects strep as the cause of the child's illness, he or she also will swab the back the throat to collect material that may harbor strep bacteria. Tests for the strep bacterium are important because a number of conditions can cause the signs and symptoms of scarlet fever, and those illnesses may require different treatments. If there are no strep bacteria, then some other factor is causing the illness.
A physician may order one or more laboratory tests such as a throat culture, which is reliable but can take up to two days to make a strep diagnosis. Another common test is the rapid antigen test, which can be completed during a physician visit and is used to detect antigens associated with strep bacteria infection but is less reliable than a throat culture.
The physician also may be able to order a relatively new rapid test that uses DNA technology to detect strep bacteria from a throat swab in a day or less. These tests are at least as accurate as throat cultures, and the results are available sooner. This would be the test of choice in an ED situation where the technology would be more readily available and quicker, more accurate results are preferred.
If the child has scarlet fever, the physician will likely prescribe a broad-spectrum antibiotic medication. If the child does not improve within 24 to 48 hours after starting the medication, the physician should be notified as the antibiotic may not be sensitive to the bacterial strain. Penicillin was the gold standard for many years, but with the emergence of resistant organisms, a culture and sensitivity is conducted on the throat scab, and other new- generation antibiotics may be necessary.
The child must complete the full course of prescribed antibiotics as directed by the physician, even when the child begins to feel better. Failure to follow the treatment guidelines may not completely eradicate the infection and will increase the child's risk of developing post-strep disorders. The child will no longer be contagious after 24 hours on antibiotics and can return to school when he or she is feeling better and no longer has a fever.
While scarlet fever seems to apply to this case given the narrative, an alternate possibility is staphylococcal scalded skin syndrome (SSSS), which presents as an acute exfoliation of the skin following an erythematous cellulitis. It is caused by an exotoxin from a staphylococcal infection.
Similar to the toxins produced by Streptococcus pyogenes, this toxin is produced by Staphylococcus aureus, a prodromal localized S. aureus infection of the skin, oral or nasal cavities, throat, or GI tract. Such an infection often is not apparent before the SSSS rash appears. Staphylococcal scalded skin syndrome presents as a red rash followed by diffuse epidermal exfoliation. There are similar symptoms common to both Streptococcus and Staphylococcus such as fever (although some patients may be afebrile), irritability, general malaise, tenderness to palpation, diffuse erythematous rash with a sandpaper-like appearance that is accentuated in flexor creases.
A difference in the presentation between the two organisms is the appearance of the skin. In a staphylococcal infection, the rash looks blistered with ill-defined blebs below the epidermis. Nikolsky's sign may be present where gentle stroking of the skin causes separation at the epidermis. Exfoliation of skin may be patchy or sheet-like in nature. Involvement may occasionally be localized or patchy rather than diffuse. Facial edema may be present, and dehydration may be significant. Most children do not appear severely ill.
SSSS primarily is a disease of children. Most children (62%) are younger than 2 years, and almost all (98%) are younger than 6 years. Reports are increasingly implicating community-acquired methicillin-resistant Staphylococcus aureus (MRSA) as a cause of SSSS. The narrative refers to staph sepsis, but this child's presentation was more in keeping with Streptococcus, particularly the necrotizing fasciitis that was the likely cause for her amputations. Definitive diagnosis for either is made virtually in the same manner through an accurate oral history from the parent, visual assessment, and laboratory testing. Antibiotics sensitive to the particular organism are ordered.
With all of this said, it is evident that the ED nurse and the PA at the first hospital encounter seriously missed the signs and symptoms of common strep or staph infection. The narrative does not indicate if an oral history was obtained from the parents of the child. Questions that should have been asked and documented include: The duration of the fever? When the rash initially started and how did it appear? How extensive was the rash? Did it look flat and angry or was it lumpy and bumpy? Was the child nauseated? How did she act before she became obviously ill? Did she complain of a headache or a sore throat? Does she have a stiff neck or swollen glands? Did she have a recent traumatic skin laceration or abrasion?
A social history also is helpful in diagnosing childhood illnesses, as children frequently spread the same illness among themselves. Does the child attend school or day care? Are any other children in the class sick? Are skin rashes going around? Is MRSA an issue at the center? Do any other family members have a cold or sore throat? Was she listless, sleepy, or lethargic? Was she irritable and cranky?
The answers to those questions are the key to substantiating the suspicion of scarlet fever or staph infection. The next step would include some form of laboratory testing to affirm the diagnosis and isolate the proper organism. The narrative does not indicate that either occurred in this scenario. The parents and child apparently left the ED without medication, which was, most likely, the root cause of the serious progression of her condition.
An accurate assessment of her mouth and throat, together with palpation of the neck, also would be telling. Given this presentation, a board-spectrum antibiotic would have most likely been effective in preventing or at least containing the ensuing sepsis until a full culture with sensitivity panel could be returned and reviewed.
This child's untreated infection led to the necrotizing fasciitis that eventually claimed her hands and feet. Had she been correctly diagnosed when her parents had first sought help, she would have been well and healthy within a week to 10 days. There was no evidence of any discharge planning in this case, which is a mandatory obligation on the part of both the attending medical staff and the hospital providing the services.
The child was referred to a pediatrician, but without the due haste that this situation demanded. The PA obviously had limited knowledge of pediatric conditions and should have consulted a physician before dismissing the child and her parents from the ED. They were not provided instructions on how to manage her care at home, what to be on the lookout for in terms of possible complications, how to safeguard the spread of the disease to other members of the household, and when the child may return to school/day care. They were given no follow-up appointments, as this type of infection should be recultured to assure that the antibiotic was effective. This child had a high fever that is more common in a bacterial infection than with a viral infection, but the PA seemed to have fixated on a viral diagnosis.
Given the long-term, life-altering impairments affecting a 4-year-old child that were obviously the result of a serious misdiagnosis, the hospital was wise to settle this case. Juries are particularly sensitive to cases involving children and the extreme suffering those children endure as a result of often careless mistakes.
(Editor's note: This case involved anonymous parties in Orange County, CA.)