Emergency Department Prematurely Discharges Child With Severe Pneumonia

This case involves a minimally verbal 12-year-old female who presented to the same hospital system pediatric emergency room multiple times over a 3 month period. She was first diagnosed with pneumonia, given a 10-day course of amoxicillin and discharged from the emergency department. She returned and was found to have pneumonia with a large loculated pleural effusion. During this hospitalization, she was given IV antibiotics and given a 10-day course of antibiotics. Only one set of blood cultures were drawn and she was discharged while it was still pending. The patient was discharged and later returned to the emergency room with abdominal pain, low urine output, and constipation. She was discharged and expired at home a few hours later. An autopsy revealed the patient expired from bacterial meningitis secondary to pneumonia. Despite this patient’s nonverbal baseline and presumed inability to clear her infection, cerebrospinal fluid was never drawn and no head imaging was ever obtained. An expert in pediatric emergency medicine was sought to review the records and opine on the standard of care.

Question(s) For Expert Witness

1. What is your experience evaluating pediatric patients with pneumonia and pleural effusion?

2. How does the infectious disease workup of a non-verbal child differ compared with a verbal child?

3. In a patient with a recent history of pleural effusions, what are the criteria for re-admission?

Expert Witness Response E-059894

As a board-certified pediatric emergency medicine physician, I have evaluated and managed many children, adolescents, and young adults with lower lobe pneumonia, including those with a pleural effusion. While there are accepted standards of care when evaluating and managing children with suspected infectious etiologies, the key with a non-verbal child is to recognize that the symptoms and signs he or she displays which may not be what is typical for a verbal child. Therefore, particular attention must be paid to potential atypical symptoms or signs, often with the help of the parent who can help delineate what is normal or abnormal for the child. Sometimes a more aggressive evaluation is undertaken with these children, balancing, of course, the risks/benefits of painful procedures to obtain laboratory testing or to administer intravenous medication. In regards to the differential diagnosis for these type of cases, it would include other causes of pain (e.g., constipation, viral etiologies, urinary tract etiologies) but a worsened pneumonia should be considered. Additionally, recurrent pneumonia or meningitis may be referred from a lower lobe pneumonia or pleural effusion. I have identified children with pneumonia based on this symptom in my clinical practice.