Hospitalist Fails To Diagnose Meningitis In Autistic Child

This case involves an autistic 11-year-old girl who presented to the pediatric emergency room with high fever, cough, and fatigue. She was diagnosed with pneumonia, given a 10-day course of amoxicillin, and discharged. The child’s symptoms worsened over the course of the antibiotic treatment and she returned to the hospital. The child was found to have fluid buildup in her lungs. She was given intravenous antibiotics and an additional 10-day course of antibiotics. She was eventually discharged from the hospital but expired at home a few days later. An autopsy revealed the child expired from bacterial meningitis. An expert hospitalist pediatrician was sought to review the records and opine on the standard of care.

Question(s) For Expert Witness

1. How does the treatment and decision to discharge a non-verbal, autistic child differ from that in a normal child?

2. How is success/failure of treatment monitored in a patient like this, in terms of repeat labs and imaging?

Expert Witness Response E-156120

I am one of the primary pediatric hospitalists at a children's hospital and I have cared for many similar patients. I cover the pediatric hospital medicine service 12 weeks a year and work 2-4 nights per month at our community hospital. I spent 5 months of my residency at a chronic care hospital for children with complex and chronic disease and 2 years of my professional career split between inpatient and outpatient medicine and during my time in the clinic. During this time, I had a significant volume of patients who were on the spectrum, allowing me to further hone my skills at caring for nonverbal, autistic children. The diagnostic and therapeutic approach to a non-verbal, autistic child is very different from the care of an otherwise healthy child. Caring for a non-verbal patient requires detailed attention to nonverbal cues, highly astute observational skills, attention to subtle clinical and historical data and a focus on all members of the team including ancillary services and family who might be able to contribute valuable data to the patient's course. The care of a child who is non-verbal and autistic is even more complicated as they are often unwilling to participate in physical exams and occasionally violently refuse physical exams. In these instances, the above is true in addition to a significant reliance on care providers who can help guide exams, calm patients and inform how to best approach these patients. While we attempt to limit unnecessary labs and images in pediatric patients, we often trend labs and images in critically ill children who are admitted to the hospital as a way of monitoring their clinical course. We rely on this data even more in a non-verbal child as it can contribute essential data that we may not otherwise be able to obtain through verbal communication and physical exams.