Patient Dies From Missed Diagnosis of Toxic Shock Syndrome

This case involves a fifty-six-year-old male, with a history of obstructive uropathy, who presented to the ED of nausea and profuse, watery diarrhea. On physical exam, he displayed left thigh pain that was significantly out of proportion to the exam. The laboratory examination was remarkable for a significant bandemia without the presence of fever or leukocytosis. The differential diagnosis in the ER was a severe UTI or possible gastroenteritis. The patient was sent home with Cipro and told to follow-up with his primary care physician. The patient returned to the ED two days later in respiratory distress and with a new rash over his face, neck, and trunk. He was admitted to the hospital and had no urine output over the next twenty-four hours. The leg pain was much worse and the patient was no longer eating or ambulating. The patient was sent to the OR for exploration of a new found abscess on an abdominal X-ray. After returning from the OR, he had rising oxygen requirements and remained intubated. Chest X-ray findings were consistent with ARDS. The patient was persistently hypotensive despite aggressive fluid replacement and support with pressors. He died due to multi-system organ failure. The OR records show that the abscess was most likely infectious myositis and the cause of death was noted as sepsis and toxic shock syndrome.

Question(s) For Expert Witness

1. What measures should have been taken to make this diagnosis earlier to save this patient?

Expert Witness Response E-001161

Prompt, aggressive exploration and debridement is absolutely indicated in patients thought to have a deep-seeded pyogenic infection, and this constitutes a surgical emergency. Surgical exploration through a small incision with visualization of the muscle and fascia may provide an early and definitive diagnosis of necrotizing fasciitis. Infection often is more extensive than is apparent from external examination. Surgical debridement of infected tissue is extremely important and often requires re-exploration to ensure adequacy of resection.