This is a 72-year-old male with World Trade Center (9/11) dust exposure (worked at Goldman Sachs near the WTC site) who has a multi-year history of recurrent episodes of cough, dyspnea, and yellow sputum production, repeatedly treated with antibiotics and corticosteroids with only transient improvement. Key events in chronological order:
January 2021: Developed fever, pain, and fatigue. Called PCP, was prescribed montelukast without improvement. Diagnosed with COVID-19 approximately one month later.
~February–March 2021: One month after COVID diagnosis, developed dyspnea and productive cough with yellow sputum. Treated sequentially with azithromycin/methylprednisolone, then levofloxacin/steroids. Symptoms recurred when steroids were stopped — particularly orthopnea (dyspnea lying down). Given an inhaler with short-term relief, then worsened again. Notably, no chest imaging was obtained during this entire period.
Mid-2021 to early 2022: Found to have a cardiac aneurysm (likely aortic or ventricular), which halted a planned EGD. Referred to cardiology. Was doing well until mid-summer 2022.
~July 2022: Cough recurred — the note mentions "cough ace," which likely refers to an ACE-inhibitor-associated cough (a medication presumably started by cardiology). Restarted inhaler with improvement. Then developed a burning sensation (possibly GERD-related, especially given the known hiatal hernia).
Late 2022: Went to cardiologist, had a CT scan. Breathing and cough worsened. Sought urgent care, treated with azithromycin and methylprednisolone. Yellow sputum resolved. CXR at urgent care reportedly normal. Patient presented to this clinic to review the CT chest.
January 2023: Cardiac catheterization revealed a 4.6 cm aortic aneurysm. Also noted to have worsening renal insufficiency.
~Early 2023: Had a colonoscopy showing 4 benign polyps and a hiatal hernia. Then developed cough again with increased dyspnea (worse supine), no fever, COVID-negative. Treated with prednisone 50 mg × 3 days (caused insomnia). No antibiotics. Symptoms improved during the day but returned at night. Yellowish sputum persisted. "Slightly better but still tight."
Later 2023–2024: Switched to Anoro (LABA/LAMA) and Flovent (ICS) as maintenance. Reports lightheadedness with Trelegy (ICS/LABA/LAMA), which he uses as needed at night for dyspnea. Continued to have increased cough, yellow sputum, and wheeze. Treated with clarithromycin and methylprednisolone. Had a recurrent exacerbation in February 2024, treated with a prednisone taper. Occasional yellow sputum production continues.
PMH:
Aneurysm of ascending aorta (4.6 cm)
Aortic insufficiency
Asthma
COPD
GERD
COVID-19
History of exposure to toxins via inhalation (world trade center exposures)
HTN
Multiple pulmonary nodules
Obstructive sleep apnea
Sinusitis with nasal polyps
Stage 3b chronic kidney disease
Meds:
albuterol (ProAir HFA) 90 mcg/actuation HFA inhaler
citalopram (CeleXA) 10 mg
dapagliflozin propanediol (Farxiga) 10 mg
fish oil concentrate (Fish Oil) 120-180 mg capsule
fluticasone (Flonase Allergy Relief) 50 mcg/actuation nasal spray
methylprednisoLONE (Medrol Dospak) 4 mg tablets
metoprolol succinate XL (Toprol-XL) 25 mg 24 hr tablet
multivitamin tablet
omeprazole (PriLOSEC) 40 mg
umeclidinium-vilanteroL (Anoro Ellipta) 62.5-25 mcg/actuation blister with device
zinc sulfate (ZI NC-15 ORAL)
zolpidem (Ambien) 10 mg
famotidine (Pepcid) 40 mg
fluticasone (Flovent) 220 mcg/actuation inhaler
losartan (Cozaar) 25 mg tablet
A follow-up "visit" occurred by phone on May 22, 2024. It appears that the Medrol Dose pak was discontinued. Patient's family indicates that patient was continuing to complain of increased shortness of breath and lethargy at this time and questions whether a phone consult was appropriate.
According to the records, the methylprednisoLONE (Medrol Dospak) was initially prescribed on February 19, 2024.
Ultimately, the patient presented to an emergency room on June 6, 2024 complaining of mid upper back pain for two days getting worse with intermittent chest tightness and shortness of breath. He was ultimately diagnosed by way of CAT scan with a Type A aortic dissection and an increasing sized thoracic aortic aneurysm which increased from 4.6 x 4.8 cm with distal tapering to 4.8 x 5.3 cm with a "new trace hemopericardium." He ultimately passed after surgery to repair.
Question is whether the administration of the steroids was inappropriate given the prior history of the aortic aneurysm and whether additional follow-up should have been undertaken by way of a personal appointment as opposed to a phone consult on May 23, 2024
Family is suspicious in that when they spoke to the pulmonologist, the pulmonologist stated "your father's breathing issue had no effect on his heart." The family questioned why he wasn't seen prior to increasing the steroid prescription. The doctor cannot answer the question and then hung up the phone.
Files:
Q: What was the patient's blood pressure at his various medical visits.
A: —
Q: Was he a smoker?
A: —
Q: what aproximate percentage of the year was the patient on steroids? Were these steroid courses sporadic?
A: —
Q: What did his PFT show?
A: —
Do you believe there might have been medical error?
My concern with so much steroid involvement is what was the prescribing physician targeting, given a patient with likely significant cardiopulmonary disease. Coughing is non-specific; the fact it was steroid responsive is a good sign that it may have been pulmonary in nature. But the chronicity of the cough at some point would warrant an exam, sputum sample, imaging, and blood work. That's the concern I have, in the setting of a known aortic aneurysm where steroids may weaken the integrity of the endothelial lining. The above requests may have led to antibiotics, for instance, or other steroid sparing interventions. I would be willing to dive further in the notes, but I cannot comment further beyond the brevity provided to me so far.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
Without an identification of what the provider felt they were treating and the lack of further testing (imaging, sputum sample, blood work), my concern is steroids were a reflexive intervention driven by a symptom and not a diagnosis that could be weighed against the known aneurysm. This does concern me, but would need to review further records.
What makes you a good expert for this case?
I'm a pulmonary physician, specializing in obstructive lung diseases, refractory chronic cough syndromes, and occupational exposures. In addition, I assist with rare diseases in our arteriovenous malformation clinic, lending me an expert as someone who understands the integrity of blood vessels.
How often do you encounter cases similar to this one in your practice?
Often. Very often. This could easily have been one of my patients.
Do you believe there might have been medical error?
The steroids were unlikely to have an impact of his aneurysm. There are many other factors that would have been more likely to contribute that have been left out of the summary
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
Steroids rarely cause rupture or harm to aneurysms.
What makes you a good expert for this case?
16years of pulmonary practice.
How often do you encounter cases similar to this one in your practice?
Often. Aneurysms like this are common as is steroid use
Do you believe there might have been medical error?
Although the case presentation focuses on whether the indication for steroids was appropriate, I would point more towards the diagnosis, follow-up, and treatment of the known thoracic aortic aneurysm (TAA). To answer the specifically asked question about the steroids, it is important to know that a TAA is not a contraindication to steroids. Furthermore, some inflammatory causes of TAA may require steroids. For example, exposure to WTC dust has been associated with sarcoidosis, which can cause TAA and need steroid Rx. However, steroid use can be an indication for more frequent follow-up of an ATT. I would also like to know whether the patient had reactive airway disease responsive to steroids or another indication for them, hence my question about the PFTs. I can indirectly assume he did, as it appears that steroid discontinuation precipitated the recurrence of symptoms. If that was the case, steroids were appropriately prescribed. However, from the case presentation, it is not clear whether the TAA was appropriately followed or treated. As another respondent asked, was the blood pressure strictly controlled, and were the beta-blockers and ARB adequately titrated? How often did the patient have imaging to follow the aneurysm size?
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
It appears that the cause of death was a dissecting aortic aneurysm. The patient did not have these symptoms during the telephone consultation. I therefore do not think that having been seen at the office would have changed the outcome. I also think the steroids were likely indicated. However, if, as it appears from the case presentation, there wasn't an adequate follow-up of the aneurysm size, determination of its cause, and medication titration, there could have been a causation of the final outcome.
What makes you a good expert for this case?
I think the best expert would be a cardiologist or a cardiovascular surgeon.
How often do you encounter cases similar to this one in your practice?
I encounter patients with aortic aneurysm repairs frequently after surgery, and I am accustomed to their care. I also encounter patients with reactive airway disease, and I have indirect exposure to patients exposed to WTC dust due to my association with NYU. However, this particular combination of WTC exposure with ascending aortic aneurysm is very infrequent. WTC exposure has not been directly linked with WTC dust.
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