Case Summary
This case involves an obese male patient with a history of Sarcoidosis, Type 2 Diabetes Mellitus, and hypertension.
After the patient’s visit to a primary care physician (PCP), a rheumatologist subsequently examined the patient for a follow-up of his Sarcoidosis. At this time, a 2-centimeter diameter area of the patient’s upper back appeared red, tender, fluid-filled, and warm. The appearance indicated potential infection. The patient was also experiencing upper nasal congestion and respiratory symptoms.
The physician prescribed the patient Methotrexate for Sarcoidosis and low dose Prednisone for his sinus symptoms. Additionally, the patient received a 7-day course of Bactrim to address the skin abscess. The physician also instructed the patient to follow up with wound care for an incision and drainage of the abscess.
The patient failed to improve after completion of the Bactrim therapy and was experiencing pain and drainage of the abscess. He visited his primary physician who prescribed Bactrim for an additional 10 days. The physician also provided a referral to general surgery for an incision and drainage of the abscess.
The physician noted the abscess but did not document the size of the lesion. In a prior visit to the surgeon, the hypertensive patient had a recorded blood pressure of 76/60 mm Hg during this visit.
Upon examination, the physician documented an abscess approximately 10×7.5cm in size. The plan was to proceed with imaging and punch biopsy, then wash out in the operating room with excision or incisional biopsy. The patient’s blood pressure was not repeated. The patient later died soon after at home. The autopsy report stated that the patient died due to sepsis secondary to a cutaneous abscess on the mid-upper back.
Case Theory
Scientific evidence provides a strong link between infectious agents and Sarcoidosis.
The PCP did not appropriately treat the patient for an abscess, leading to sepsis and death. Severe infections are observed in 5.1% of patients afflicted with Sarcoidosis. Risk factors for severe infections include neurological or cardiac involvement with Sarcoidosis, along with the use of immunosuppressive agents and mainly Cyclophosphamide.
Sarcoidosis is an inflammatory disease whose pathophysiological mechanism is immunological but still misunderstood. It is an exaggerated immune response and granulomatous reaction to unidentified antigens, both environmental and transmission agents.
The treatment of symptomatic Sarcoidosis usually includes glucocorticoids and cytotoxic drugs like Methotrexate, Azathioprine, Cyclophosphamide, Mycophenolate Mofetil, and biologic agents. The use of immunosuppressive drugs is associated with an increased risk for infection. The decision to treat with Bactrim, particularly when the first course of therapy was unsuccessful, is in question. The physician failed to examine bloodwork to determine potential infection. There were also no pathology reports present.
Expert Witness Questions
- Is an improvement in monitoring and measurement of the abscess size and progression warranted in this case?
- What is the standard of care as it relates to the treatment of a worsening abscess in an immunosuppressed patient with poorly controlled diabetes on Methotrexate therapy?
- Was Bactrim the best choice for infection here?
- Should a low blood pressure reading in a hypertensive patient with signs of infection alert the physician to the need for further exploration?
- Should the physician have ordered a pathological identification of the infection to determine the agent of infection?
- Was blood work indicated in this case?
Expert Witness Involvement
Primary Care Physician
A primary care expert can speak to the standard of care and deviations from the standard of care for this patient.
Rheumatology Expert
Rheumatology specialists can speak to the risk of infection, the need for treatment, and the proper medications, investigation, and follow-up for skin abscess in Sarcoidosis.
Infectious Disease/Wound Care Expert
An infectious disease expert with a specialty in wound care is familiar with skin abscesses and proper antibiotic use for best outcomes in a patient with complicated Sarcoidosis and suppressed immune system. This expert can speak to the standard of care in this case and the need for a follow-up in a progressive wound with failure to heal.
General Surgeon
A general surgeon can identify whether the physician followed the standard of care, examined the wound pathology, and gave proper treatment in this case.
About the author
Erin O'Brien
Erin O'Brien is a senior medico-legal writer and editor, with 25 years of experience authoring healthcare deliverables. Previously, Erin authored an award-winning column in the health and wellness sector, guest hosted a wellness radio show, and received an FMA Charlie Award for Excellence in Writing.
Erin has reviewed and completed case studies for thousands of medical malpractice cases, both plaintiff and defense nationwide, and was presented the US Chamber of Commerce Best Small Business Blue Ribbon designation. Erin is an experienced Medical Risk Consultant and device start-up project manager. She has consulted for numerous successful healthcare and bio-tech start-ups. After completing a Bachelor of Science degree at the University Of Wisconsin, Erin pursued an educational background in Healthcare Risk Management at the University of South Florida. Erin crafts her work with attention to detail, readability, healthcare marketing regulations, and medical standard of care.
