Patient Dies From Delayed Treatment of Pneumonia

Case Overview

This case takes place in Indiana and involves a female patient with a past medical history of multiple chronic conditions. The patient had presented to the ER due to complaints of chest pain and shortness of breath. Once at the hospital, an abdominal x-ray was performed, which revealed a band of density in a small section of her lungs, however her lungs were otherwise clear. However, there was large amounts of stool intermixed with air throughout the colon, which was compatible with fecal impaction or constipation. Several additional tests were preformed at this point, one of which detected an elevated white blood cell count, however the patient was diagnosed with constipation and sent home.

Some time after initially leaving the hospital, the patient presented to the ER again complaining of symptoms of dehydration. A chest x-ray showed massive right pneumonia. Antibiotics were started immediately, however she had a spiking fever and a diagnosis of severe sepsis and septic shock. The patient was admitted to the ICU, where she succumbed to her pneumonia and died.

Questions to the Infectious Disease and Communicable Disease expert and their responses

What is the normal work-up for a patient presenting with these signs and symptoms?

It's crucial to know if the spiral CT was done of the chest as well as part of an exclusion for pulmonary embolism. The CT would be much more sensitive than the CXR.

Should the patient have been discharged without her elevated WBC being addressed?

The elevated WBC is nonspecific, and while it's tempting to imply that this was a forme fruste of pneumonia, I have personally been consulted many times for such a condition where the WBC is due to constipation and pain, and there are no dire consequences. I'm wondering why he was manually disimpacted, and why an enema was not given in the ED to facilitate improvement.

Had the patient's pneumonia been diagnosed sooner, could the outcome have been better?

It's also crucial to know what was happening with the patient in the 5 days between. Was he home vomiting, suggesting development of obstruction, and then developing aspiration pneumonia from this? This case would require teasing out the ED visit and follow up 5 days before the ED presentation.

About the expert

This double board certified expert has been practicing for over a decade. She earned her medical degree from Loyola University Chicago and completed her residency in Internal Medicine at the University of Chicago, where she also completed a fellowship in Infectious Diseases. Currently, she is an Assistant Professor of Medicine at a major medical university, an Attending Physician on the General Infectious Diseases Service of her institution's hospital affiliate, as well as the Medical Director of both the Infection Control Program and the Antimicrobial Stewardship Program. She shapes policy and practices regarding antimicrobial use by all providers within the medical center and was awarded the American Society of Health System Pharmacists Best Practice Award for her work. She is also responsible for curriculum development and training of all employees and faculty with respect to infection prevention and hospital infection control policy.

E-007980

Specialties:

Infectious Disease and Communicable Disease