WebM&M: Case Studies

This case describes a 55-year-old woman who sustained critical injuries after a motor vehicle crash and had a lengthy hospitalization. On hospital day 30, a surgeon placed a percutaneous endoscopic gastrostomy (PEG) tube in the intensive care unit (ICU) after computed tomography (CT) scan showed no interposed bowel between the stomach and the anterior abdominal wall.  After the uncomplicated PEG placement, the surgeon cleared the patient’s team to advance tube feeds as tolerated. After several weeks of poorly tolerated tube feedings, the interventional radiology team reviewed a CT scan which had been obtained by another service 6 days after the PEG was placed and noted (for the first time) that the gastrostomy tube traversed the liver. Insufficient communication and fragmented care coordination across care settings contributed to poor management of the malpositioned PEG tube. The commentary underscores the importance of clear documentation of complications, highlights best practices to mitigate risks during patient care transition, and the importance of using multiple communication approaches to ensure appropriate continuity of care.

This case describes the failure to identify a brewing abdominal process, which over the span of hours led to fulminant sepsis with rapid clinical deterioration and eventual demise. The patient’s ascitic fluid cultures and autopsy findings confirmed bowel perforation, but this diagnosis was never explicitly considered. The commentary discusses the importance of early identification of sepsis, the role of biomarkers and risk scores in conjunction with bedside examinations to assess patients with suspected sepsis, and approaches to improve the prognosis of patients in septic shock, such as protocolized sepsis bundles.

This case describes a man in his 70s with a history of multiple myeloma and multiple healthcare encounters for diarrhea in the previous five years, which had always been attributed to viral or unknown causes, without any microbiologic or serologic testing. The patient was admitted to the hospital with gastrointestinal symptoms and diagnosed with cholecystitis and gangrenous gallbladder. Two months after his admission for cholecystitis, he was readmitted for severe vomiting and hypotension. An upper gastrointestinal endoscopy with biopsy unexpectedly showed that his duodenum was heavily infiltrated with a parasitic helminth (worm) called Strongyloides stercoralis. He was treated with the anti-parasitic drug ivermectin and eventually improved enough to be discharged from the hospital. The commentary summarizes factors contributing to the missed diagnosis of strongyloidiasis, potential consequences of a failure to diagnose this infection, and approaches to identify patients who should be tested for Strongyloides infection.

A 49-year-old woman was referred by per primary care physician (PCP) to a gastroenterologist for recurrent bouts of abdominal pain, occasional vomiting, and diarrhea. Colonoscopy, esophagogastroduodenoscopy, and x-rays were interpreted as normal, and the patient was reassured that her symptoms should abate. The patient was seen by her PCP and visited the Emergency Department (ED) several times over the next six months. At each ED visit, the patient’s labs were normal and no imaging was performed. A second gastroenterologist suggested a diagnosis of intestinal ischemia to the patient, her primary gastroenterologist, her PCP, and endocrinologist but the other physicians did not follow up on the possibility of mesenteric ischemia. On another ED visit, the second gastroenterologist consulted a surgeon, and a mesenteric angiogram was performed, confirming a diagnosis of mesenteric ischemia with gangrenous intestines. The patient underwent near-total intestinal resection, developed post-operative infections requiring additional operations, experienced cachexia despite parenteral nutrition, and died of sepsis 3 months later.  The commentary discusses the importance of early diagnosis of mesenteric ischemia and how to prevent diagnostic errors that can impede early identification and treatment.

A 58-year-old man with a past medical history of seizures presented to the emergency department (ED) with acute onset of left gaze deviation, expressive aphasia, and right-sided hemiparesis. The patient was evaluated by the general neurology team in the ED, who suspected an acute ischemic stroke and requested an evaluation by the stroke neurology team but did not activate a stroke alert. The stroke team concluded that the patient had suffered a focal seizure prior to arrival and had postictal deficits. The stroke team did not order emergent CT angiography and perfusion imaging but recommended routine magnetic resonance imaging with angiography (MRI/MRA) for further evaluation, which showed extensive cerebral infarction in the distribution of an occluded left middle cerebral artery (MCA). Due to the delayed diagnosis of left MCA stroke, it was too late to perform any neurovascular intervention. The commentary highlights the importance of timely use of stroke alert protocols, challenges with CT angiography in early acute ischemic stroke, and the importance of communication and collaboration between ED and neurology teams.

A 65-year-old woman with a history of 50 pack-years of cigarette smoking presented to her primary care physician (PCP), concerned about lower left back pain; she was advised to apply ice and take ibuprofen. She returned to her PCP a few months later reporting persistent pain. A lumbar spine radiograph showed mild degenerative disc disease and the patient was prescribed hydrocodone/acetaminophen in addition to ibuprofen. In the following months, she was seen by video twice for progressive, more severe pain that limited her ability to walk. A year after the initial evaluation, the patient presented to the Emergency Department (ED) with severe pain. X-rays showed a 5 cm lesion in her lung, a small vertebral lesion and multiple lesions in her pelvic bones. A biopsy led to a diagnosis of lung cancer and magnetic resonance imaging (MRI) showed metastases to the liver and bone, as well as multiple small fractures of the pelvic girdle. Given the extent of metastatic disease, the patient decided against aggressive treatment with curative intent and enrolled in hospice; she died of metastatic lung cancer 6 weeks after her enrollment in hospice. The commentary summarizes the ‘red flag’ symptoms associated with low back pain that should prompt expedited evaluation, the importance of lung cancer screening for patients with a history of heavy smoking, and how pain-related stigma can contribute to contentious interactions between providers and patients that can limit effective treatment.

A 44-year-old man presented to his primary care physician (PCP) with complaints of new onset headache, photophobia, and upper respiratory tract infections. He had a recent history of interferon treatment for Hepatitis C infection and a remote history of cervical spine surgery requiring permanent spinal hardware. On physical examination, his neck was tender, but he had no neurologic abnormalities. He was sent home from the clinic with advice to take over-the-counter analgesics. Over the next several days, the patient was evaluated for the same or similar symptoms again by his PCP and was seen by the emergency department and urgent care clinics before being admitted to the hospital; however, he was misdiagnosed with Staphylococcal meningitis, and it was not until his third inpatient day when cervical magnetic resonance imaging (MRI) showed a spinal epidural abscess. The commentary discusses the multiple factors leading to erroneous interpretation tests for spinal epidural abscess and the importance of broadening differentials and avoiding premature closure during diagnosis.

A 52-year-old man complaining of intermittent left shoulder pain for several years was diagnosed with a rotator cuff injury and underwent left shoulder surgery. The patient received a routine follow-up X-ray four months later. The radiologist interpreted the film as normal but noted a soft tissue density in the chest and advised a follow-up chest X-ray for further evaluation. Although the radiologist’s report was sent to the orthopedic surgeon’s office, the surgeon independently read and interpreted the same images and did not note the soft tissue density or order any follow-up studies. Several months later, the patient’s primary care provider ordered further evaluation and lung cancer was diagnosed. The commentary discusses how miscommunication contributes to delays in diagnosis and treatment and strategies to facilitate effective communication between radiologists and referring clinicians.  

A 56-year-old women with a history of persistent asthma presented to the emergency department (ED) with shortness of breath and chest tightness that was relieved with Albuterol. She was admitted to the hospital for acute asthma exacerbation. Given a recent history of mobility limitations and continued clinical decompensation, a computed tomography (CT) angiogram of the chest was obtained to rule out pulmonary embolism (PE).  The radiologist summarized his initial impression by telephone to the primary team but the critical finding (“profound evidence of right heart strain") was not conveyed to the primary team. The written radiology impression was not reviewed, nor did the care team independently review the CT images. The team considered her to be low-risk and initiated therapy with a direct oral anticoagulant (DOAC). Later that day, the patient became hemodynamically unstable and was transferred to the intensive care unit (ICU). She developed signs of stroke and required ongoing resuscitation overnight before being transitioned to comfort care and died. This commentary discusses the importance of avoiding anchoring bias, effective communication between care team members, and reviewing all available test results to avoid diagnostic errors.