October 1, 2021, patient reported foot problems during a primary care visit to doctor. During that visit he reported a painful and swollen right foot and a swollen left foot that was aggravated during the workday. He reported red discoloration on his left foot. Patient was diabetic and the issue was treated as a diabetic ulcer. He continued to see the doctor almost monthly, as condition became progressively worse. Uploaded photos taken at the facility depict the progression of the condition.
In January 2022, dermatologist diagnosed the condition as contact dermatitis. On March 4, 2022. was seen at the ED and reported that “about 3 to 4 days ago he noticed an ulcer in the plantar aspect of his left foot,” “with some redness around it,” and that “a couple days ago it was bleeding, and he noticed some drainage from it.” The emergency room examination revealed the following:
“Interdigital spaces with maceration. No fluctuance or crepitus noted to the left foot. 0.5 cm x 0.5 cm fluid filled blister noted to the plantar aspect of the left foot, proximal to the 1st metatarsal head. Upon a stab incision to the blister, serous drainage of expressed. No purulence was expressed. No sinus tracking, probe to bone, or malodor noted. Positive for peri wound erythema and edema. Irregular indurated skin noted surrounding the blister. Erythema diminished mildly with elevation of the left lower extremity.”
He was given antibiotics and diagnosed with cellulitis. Photos were taken at that time and show the progression of the condition.
On March 9, 2022, patient was seen by wound care, during this visit, it was reported that the left foot had, “dark papules bilateral foot with additional skin changes consistent with long standing tinea pedis” and a “tender ulcer left medial arch, no deep probe, no purulence, no erythema." The patient was diagnosed with an ulceration of the left foot, DM2, Tinea Pedis and was prescribed antifungal medication.
On March 15, 2022, patient was seen in Dermatology and the diagnosis was changed to “Neoplasm of Uncertain Behavior,” “Ulcer of Left Foot, Unspecified Depth,” and “DM2.” A shave biopsy of the left foot was taken from the “dorsal L foot.” Only 1 location was tested, and no punch biopsy was performed. Patient's A1C taken on March 25, 2022, revealed his average glucose level had reduced from 9.5 in November 2021 to 6.9.
March 31, 2022, he returned to Dermatology for a recheck. During this visit he was diagnosed with Stasis Dermatitis and a rash of the left foot. He prescribed Clobex topical lotion. Patient continued to be seen on several occasions in March, April and May and condition continued to worsen. Photos taken at these exams have been uploaded. His condition continued to be identified as left foot swelling, stasis dermatitis and ulceration related to patient's DM2.
On May 26, 2022, patient was again prescribed a topical lotion Clobex, but no antibiotics were prescribed for the wound and condition that remained unhealed for almost 5 months. Patient still had limited mobility without crutches. He was still unable to work.
In June of 2022, because his condition continued to worsen despite his regular visits to the facility, the Patient decided to obtain second opinion from his native country of Mexico. Punch biopsies taken revealed the following:
“MACROSCOPIC DESCRIPTION: The specimen consists of two-foot segments, with cellular tissue subcutaneous, are: oval, asymmetrical, violet, red in color, soft in consistency, granular, 1.4 and 1.9 cm, in their largest diameters, with a reticular and opaque skin surface.
MICROSCOPIC DESCRIPTION: The histological sections show a proliferation of cells.
elongated, fibrillar, straight or tortuous, with a faint or clear acidophilic cytoplasm, with a membrane thin, constant and fused in frequent segments; Its diameter is intermediate and the nuclei are subcentral, ovoid or elongated, with blunt ends, with a poorly reinforced membrane and chromatin condensed, well distributed, in prominent segments and without nucleoli, with a growth pattern solid or indefinite, with numerous thin-walled vascular spaces, with abundant erythrocytes in the lumen, with small lymphocytes and occasional plasma cells.
DIAGNOSIS: MORPHOLOGICAL ELEMENTS, CORRESPONDING TO A KAPOSI SARCOMA”
Patient subsequently underwent chemotherapy treatment in Mexico and then returned to the facility in the United States. It was not until October of 2022, that the facility in California performed its own punch biopsies and confirmed the diagnosis of Kaposi Sarcoma. At that time, radiation treatment was recommended.
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Do you believe there might have been medical error?
The case chronology and progressive clinical presentation of the lesions on the patient's left foot and leg in the January 2022 photographs is highly consistent with Mediterranean-type Kaposi's sarcoma (KS) at less likely, another form of sarcoma or atypical skin infection. KS typically arises on the lower extremities of the lower legs of older men of Mediterranean ancestry. It commonly presents as red, dusky red, purple or brown nodules or plaques. Although the patient may have had chronic tinea pedis and stasis dermatitis, these are very often bilateral and differ significantly from KS. The left plantar plaque is particularly worrisome and merited an early biopsy, absent of the other lesions. Although the history given states that monthly photographs were taken by the primary care physician starting in October 2021, these are not provided. Three months later, in January 2022, it was below the standard of care for the dermatologist to consider the condition to be contact dermatitis and not suspect KS, as the pictures provided are highly suggestive for KS. A biopsy would have been highly appropriate then. It will be important to know the results of the biopsy the dermatologist did take on in March 15, 2022, as this is mentioned in the history but not provided.. For the dermatologist not to suspect KS while seeing the patient from January through May 26, 2022 continuing to call the condition stasis dermatitis and ulceration related to patient's DM2 and not biopsy lesions is well below the standard of care.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
The degree to which the delayed diagnosis caused injury depends on when the KS could have been diagnosed and treatment initiated. Localized KS can be treated with local treatments including cryotherapy, topical and intralesional therapy. Slightly more advanced disease can be treated with radiation therapy. Extensive disease requires chemotherapy, immunotherapy or radiation therapy. It is as yet unclear how extensive the KS was when patient presented to the primary care MD in October 2021. This can be assessed by the pictures the history states the primary care MD took and by further discovery and the deposition of the patient. However, he was already having difficulty walking. So the question is, 1) what increase in disability and pain did the patient experience between October 2021 and June 2022, when KS was finally diagnosed in Mexico, and 2) would earlier treatments have been less intense, invasive and of lower risk and morbidity if treatment had been instituted earlier. From my experience in past expert witness cases, the Defense will likely try to claim that the delay in diagnosis and treatment did not significantly affect the patient's final therapy.
What makes you a good expert for this case?
I have seen and treated multiple cases of Mediterranean KS. Most were during my residency and when I was in charge of the dermatology section at the La Jolla VA hospital. I saw and treated additional cases while training at the tertiary referral center for dermatology in the United Kingdom, St. John's Hospital for Diseases of the Skin.
How often do you encounter cases similar to this one in your practice?
Later in my career, my practice was devoted to skin cancer, so recent experience is limited.
Do you believe there might have been medical error?
The appearance of the foot is typical for Kaposi Sarcoma and unusual for allergic contact dermatitis.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
Delay in diagnosis allowed the tumor to progress before intervention could be be initiated.
What makes you a good expert for this case?
I am a board-certified dermatologist and Mohs surgeon.
How often do you encounter cases similar to this one in your practice?
While Mohs surgeons are experts in skin cancers, we do not typically treat Kaposi sarcoma. I encounter them rarely and refer them on to other non-dermatology experts for treatment.
Do you believe there might have been medical error?
There may have been a medical error because there was continued medical management despite no improvement, and attempts to diagnose (ie culture, biopsy) was initially not performed. Secondly - while a shave biopsy was initially performed, and did not yield a satisfactory explanation for the patient's symptoms, a second deeper ie punch biopsy should have been performed.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
A delay in patient's diagnosis may have lead to morbidity, and prolonged treatment.
What makes you a good expert for this case?
I have almost 10 years of experience practicing general medical dermatology in an academic center. A large portion of my time is spent in a safety net clinic where we see a diverse patient population and skin conditions the average general dermatologist likely does not see. In addition, 2 days a week, I oversee a leg ulcer clinic where we see a diverse range of rashes and ulcers on the legs and feet.
How often do you encounter cases similar to this one in your practice?
I see cases similar to this several times per year.
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