Infectious Disease Expert Advises On Infection Resulting In Amputation Of Both Arms

This case involves a patient, located in Connecticut, who underwent a CT scan which revealed a loculated cyst, pseudocyst, or cryptic mass at the head of her pancreas. The patient reported severe back and stomach pain as well as vomiting and chills. The patient presented to the ER. Lab results showed leukocytosis. Doctors requested a GI consult for endoscopic ultrasound. Instead, an ID consult was performed, at which time a gram smear revealed positive cocci in groups. The patient underwent EUS with fine needle aspiration. The patient had a protracted, complicated clinical course due to MRSA sepsis. The patient underwent three open abdominal surgical procedures for irrigation and vac management. The patient developed vent-dependent respiratory failure, ultimately requiring tracheostomy. The patient required peritoneal dialysis for ARF, placement of a feeding tube, and a PICC line for antibiotic therapy. The patient also required multiple pressors for hemodynamic support and developed severe coagulopathy, with questionable shower emboli. It is alleged that the patient was not given the necessary treatment and as a result developed upper and lower extremity ischemia. The lower extremities were salvaged but the patient required bilateral upper extremity amputation, right arm above and left arm below-elbow. The patient was noted to be displaying digital gangrene. It is believed the defendants did not take the necessary precautions and steps to ensure the patient did not develop infections. She required amputation of both her arms.

Question(s) For Expert Witness

1. What steps should be taken when cysts are discovered on patients?

2. What treatment should be given to patients complaining of pain or discomfort related to a cyst, abscess?

3. What is your experience with pre/post Op care specifically to prevent infections?

Expert Witness Response

This presentation is extremely complex. A lot of information needs to be teased out to make these assessments. I have extensive pre and post operative infectious disease experience. Depending on the clinical details, pancreatic cysts may be bland or become infected. If it appears the cyst is infected, then it should be drained and appropriate IV antibiotics should be used. For pancreatic phlegmons and abscesses, the clinical course can be very protracted and rocky, even when standard of care is met. Sounds like the patient had metastatic staphylococcus aureus infection, with perhaps poor source control.