ONLY INFECTIOUS DISEASE SPECIALIST SHOULD REPLY OR A PRACTITIONER WHO DIAGNOSES AND TREATS CRYPTOCOCCUS NEOFORMANS.
61 y/o/male seen at hospital 9/13/19 for c/o dysarthria. MRI brain reports "subtle flair hyperintense signal within a few sulci within the bilateral parieto occipital regions and frontal high convexities. Meningitis cannot be excluded. Consider post contrast MR to evaluate enhancement which would support underlying infection." Contrast study not performed and patient discharged next day. Readmitted 9/21 until death on 10/8. BC positive for cryptococcal antigen. Therapy started on 9/27 with cefepime 2gm q8h, vancomycin 2.25gmq8h loading then 1.25gmq8h and amphotericin B 400mg q24H. Pt expires 10/8.
Had the fungal infection been diagnosed and treated 10-12 days earlier, more likely than not, would the patient have survived?
Did the MRI findings require further investigation with contrast?
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Do you believe there might have been medical error?
It is difficult to make that judgement based on the case details. Patients with cryptococcal meningitis typically present with fever, neck stiffness, photophobia, and other signs of CNS infection, and these infections occur most often in patients with compromised immune systems. If this patient did not present with those symptoms and was not immunocompromised then a medical error seems unlikely.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
As details above, a medical error seems unlikely based on the provided details.
What makes you a good expert for this case?
I am an infectious diseases physician who has treated 20-30 cases of cryptococcal infection.
How often do you encounter cases similar to this one in your practice?
I see a new patient with a cryptococcal infection every 2-3 months.
Do you believe there might have been medical error?
1). The patient should have undergone a lumbar puncture to rule out meningitis. He may not have had fever or chills but this could have been an atypical or carcinomatous meningitis or multiple sclerosis. An additional MRI with contrast may or may not have provided any additional information. Often, one just needs to collect spinal fluid counts to see what is happening in CSF. One would need to see the reasoning of the ED MD why lumbar puncture was not performed.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
Cryptococcal meningitis has worse prognosis if there any neurological signs (such as dysarthria) but so is delayed of treatment. Even though cryptococcal meningitis is rare in non-HIV patients, the ED physician likely did not know if the patient was HIV positive or HIV negative. Lumbar puncture should have been done in the ED.
What makes you a good expert for this case?
Sixteen years of ID experience in a variety of settings in this country and overseas. I do my own lumbar punctures.
How often do you encounter cases similar to this one in your practice?
Cryptococcal meningitis is not common in non-HIV patients. I see meningitis patients several times a year.
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