This case involves a 23-year-old female patient who was treated at a wound care clinic for several open arm wounds. The bandages were described as foul-smelling and greenish-blue in color, and she had developed clear signs of infection. The clinic obtained cultures of the wounds, however preliminary results came back as negative. The wound care clinic referred the patient to her primary care physician. The primary care physician noted a diffuse rash but did not suspect infection because the wound clinic did not send a follow up regarding the final culture report. Several days later, the patient went into septic shock from a bacterial infection. The patient was unable to recover and succumbed to the sepsis in a few days. It was later discovered that the wound clinic did render a final report and that the bacteria which caused the patient’s infection were present in the report. It was alleged that the primary care physician was negligent in failing to follow up with the wound care clinic regarding the final culture report.
Question(s) For Expert Witness
1. What is the differential diagnosis in a patient like this who develops a diffuse rash? 2. What is the appropriate work-up for this patient as an outpatient? 3. Is the primary care physician obligated to inquire about and/or follow up final culture reports ordered by a wound care specialist?
Expert Witness Response E-116683
The differential for a diffuse extremity rash includes:
a) cellulitis (superficial soft tissue infection)
b) chronic venous stasis
c) skin changes related to venous thrombosis (clotting)
d) other causes of rash as a primary problem (contact dermatitis, psoriasis, etc), or related to other diseases (e.g., erythema nodosum or vasculitic changes).
Because of the patient's chronic wounds, if those wounds are deep enough, a bone infection (ostemyelitis) might also develop and this may not be directly related to the rash. Wound cultures would be appropriate if the wounds are purulent and not healing well. If there are clinical signs of cellulitis, it is difficult to culture and is often treated empirically. I would send blood cultures and ESR and possibly do bone imaging if there were constitutional and laboratory signs of a widespread infection. Certainly if the primary care physician was aware the cultures were done, he/she should have followed up the results. If the patient was presenting with signs of infection, a review of past labs and studies and a set of new studies would be appropriate. In the event that the wound care specialist and primary care physician do not share the same electronic health records system, obtaining the past impressions and testing may be a challenge. It is good clinical practice for the wound care clinic to forward clinical information to the primary care physician, but this communication does not always take place.