This case takes place in New York and involves a female patient with a past medical history of hypertension, high cholesterol, and obesity. The Plaintiff initially presented to the hospital complaining of diarrhea and vomiting along with a chronic cough. She was taking a variety of medications, including Benicar and Lipitor, and she initially believed she was suffering from side effects of the medications. However, once she arrived at the hospital she was diagnosed with gastroenteritis and discharged. The Plaintiff was seen again at the same hospital multiple times over the course of several months presenting a multitude of symptoms including fatigue, dizziness, discomfort breathing, chills, and chest pain. After these visits, she was diagnosed with suspected pneumonia, in addition to a host of other speculative diagnoses. Her blood work showed an elevated white blood count and low hemoglobin. Eventually, a biopsy was performed, which revealed that Plaintiff had acute leukemia. The Plaintiff then underwent a series of treatments over the course of several weeks. Eventually, she developed a fever and was subsequently diagnosed with an antibiotic-resistant infection. The symptoms of this infection persisted, until she suffered a massive heart attack and was pronounced dead.
Question(s) For Expert Witness
- 1. At what point in the diagnosing process do you usually consult/evaluate patients?
- 2. How many patients on average do you diagnose within a year and how long does the diagnosis process take?
- 3. Given the patient's presenting complaints what should have been the differential diagnosis?
Expert Witness Response E-000029
In cases like this, I usually consult/evaluate patients once an abnormality on the Complete Blood Count had been identified. On average, I see 6-10 AML patients a year, a few of whom I diagnose. Prior to 2008 when I left my academic position and went into private practice, about twice that many. I have never improperly diagnosed or failed to diagnose a patient with leukemia. Given the patient’s presenting complaints, there could have been a different diagnosis. Any elevated white count should bring up the possibility of acute leukemia. There is usually something in the CBC report that gives it away and there may be something in this case, which will make the failure to diagnoses earlier more egregious. The issue then is a delay in diagnosing acute leukemia. While there is not much literature on delayed diagnosis in AML, because it is a rapidly fatal disease if not diagnosed, my opinion would be that delay allowed her leukemia to progress and made treatment more difficult to treat. I note the weight loss, which makes her more susceptible to complications and the apparent progression from slightly elevated white counts mimicking infection to such high counts that she required leukophoresis. High white count at diagnosis is a poor prognostic feature. In summary, the delay in treatment allowed her leukemia to progress.
Expert Witness Response E-009356
I diagnose 60-100 patients with cancer a year, and rule out cancer in many more. Diagnosis of acute leukemia can take 5 minutes, just by looking at the blood smear, or last as long as a week if complex tests are required to diagnose the particular subtype of leukemia for treatment planning purposes. The signs of acute leukemia are hard to miss: fatigue; weight loss; night sweats; bleeding or bruising; frequently signs of infection, such as fever or pneumonia; sometimes enlarged lymph nodes or spleen. The bulk of my clinical work is inpatient consultation, consisting of new diagnosis and treatment planning. I am consulted as soon as there are hematological abnormalities, fevers of unknown origin, systemic symptoms such as unexplained weight loss, abnormal imaging or physical exam in a patient. I see inpatient consultations within 2-3 hrs of being consulted, which is why I wonder after the bone marrow biopsy in this case took so long to follow up.