Looking for review of Pulmonary/Critical Care Medicine:
65 year old male presents to emergency department just before 1:00 a.m. on November 26, 2021. The “chief complaint” documented in the emergency department records was: “pt accompanied by brother who reports pt has had change in mental status today, pt alert and confused, last normal ‘yesterday.’” He was evaluated by emergency physician, who noted that the patient was confused, with a history of fever, vomiting, and diarrhea that had started five days earlier. A CT of the head and chest x-rays showed no acute abnormality.
It appears ER doctor suspected possible encephalitis or meningitis, but noted that a lumbar puncture was unable to be performed in the emergency department because patient was being ventilated with a BiPAP machine for hypoxia. ER doctor started patient on empiric intravenous acyclovir, along with antibiotic medications. The patient received his first treatment of acyclovir via IV piggyback starting at 5:19 a.m. and ending at 6:19 a.m. on November 26, 2021.
The patient was admitted the morning of November 26, 2021 to the hospitalist service. Order details include: “fever of unknown origin, confusion, pulmonary edema, possible meningitis/encephalitis.” Over the next several hours, the hospitalist requested critical care consult but did not enter any orders for medications.
Critical Care Consultation performed at 12:39 p.m. and noted patient has pending LP. His plan included: (1) Close ICU hemodynamic monitoring; (2) Transition off BiPAP to heated high flow and wean as tolerated; (3) Continue cefepime, add vancomycin for meningitis coverage until LP done; (4) Encephalopathy acute likely also secondary to sepsis given pneumonia; (5) LP ordered, INR is 1 will await results; (6) floow blood cultures; (7) HIV and hep panel negative; (8) Covid and viral panel negative; (9) Trend LFTs; and (10) monitor creatinine urine output.
Neither hospitalist nor critical care physician continued the acyclovir. Critical Care Physician did not appreciate that the PCR test for herpes simplex virus on the CSF fluid had not been ordered.
The morning of November 27, 2021, the hospitalist assessed the patient as having suspected pneumonia, sepsis, and acute metabolic encephalopathy. He noted that cerebrospinal fluid cultures from the patient's lumbar puncture had been negative, and that the patient was receiving vancomycin and cefepime.
Two days later on November 29, 2021, the hospitalist ordered an infectious disease consult. The infectious disease doctor saw the patient the same day, and immediately ordered a PCR test for herpes simplex virus on the CSF fluid sample that had been collected three days earlier. At two p.m. that day, the test results came back positive for herpes simplex virus 1.
It appears that these critical test results may not have been reported until the following morning. For whatever reason, the hospitalist finally entered an order to restart the patient's IV acyclovir at 10:34 a.m. on November 30, 2021. The patient received his second dose of acyclovir at 12:31 p.m. on November 30, 2021. Unfortunately, he suffered significant brain damage from the herpes encephalitis.
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Do you believe there might have been medical error?
Herpetic encephalitis is clearly in the differential diagnosis of fever and confusion. Accordingly, the ER physician suspected the diagnosis and initiated empiric treatment. When the treating physicians decided to discontinue acyclovir, they cited metabolic encephalopathy as the cause for the patient's symptoms. While, this was also a likely explanation, it is a diagnosis of exclusion. Furthermore, the ER physician had suspected the diagnosis, and it does not appear from the history that the treating physicians explained their rationale for actively discontinuing empiric treatment. Omission of HSV PCR from the CSF is also an inadmissible error. CSF is difficult to obtain, so once the LP perform, all studies must be undertaken.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
It also very likely that the delay contributed to the patient's permanent neurologic damage, as time is of the essence in treating HSV encephalitis. Because the patient consulted within the first day of symptoms, and was alert at presentation, it is very likely that treatment continuation on admission to the hospital would have averted disease progression and the patient would have had a better neurologic prognosis. Although most patients with herpetic encephalitis have neurologic sequelae, acyclovir is an effective treatment and timely treatment can greatly reduce the severity of such sequelae.
What makes you a good expert for this case?
I am an intensive care physician, and have practiced as a hospitalist. I work within the scope of practice of the involved physicians, Involving an ID physician as well can provide further support for the case
How often do you encounter cases similar to this one in your practice?
Herpetic encephalitis is a rare condition. As such, I infrequently see cases such as this one (less than once a year). That being said, physicians are trained to recognize infrequent but severe conditions, such as this one
Do you believe there might have been medical error?
This patient had meníngeo encephalitis . The most treatable cause of encephalitis is HSV-1. Since the acyclovir was ordered empirically for viral meníngeo encephalitis, which was right decision, and then the order not continued, and patient had HSV 1 encephalitis, then this is a medical error.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
Untreated HSV -1encephalitis. Goal of sepsis treatment is source control and delivery of Antibiotics. In this case delay in AB treatment and/or continuation was associated with poor source control.
What makes you a good expert for this case?
years in clinical practice, almost two decades and serving as expert almost. a decade.
How often do you encounter cases similar to this one in your practice?
Infrequently as these are rare. But as we are a referral center, then we see couple in a year.
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