This case involves a young male patient in Ohio who presented to the emergency room with complaints of back pain that had lasted several days. After a brief physical evaluation, the patient was prescribed a muscle relaxant and discharged without any lab studies or imaging. A few days later, the patient presented to another hospital emergency room with the same complaints of back pain. During this visit, he was quickly diagnosed with musculoskeletal back pain and discharged. The next day, the patient presented to the emergency room a third time with new complaints of nausea, vomiting, and difficulty thinking. The emergency room physician ordered a complete blood count with differential and erythrocyte sedimentation rate (ESR) that showed an elevated white blood cell count, as well as elevated levels of a specific type of white blood cells and elevated ESR. An MRI was ordered and performed, however the treating physician noted that the MRI was non-diagnostic. The doctor claimed that the abnormal lab results could be explained by any number of other conditions, so he wasn’t concerned with the values. The patient was then discharged with a diagnosis of unspecified back pain. No repeat MRI or follow-up was ordered. The patient presented several hours later for another hospital visit, and was promptly discharged. The patient eventually died, with the cause of death being listed as bacterial meningitis.
Question(s) For Expert Witness
- 1. Do you routinely treat patient like the one described in this case? Have you ever had a patient develop this outcome?
- 2. Based on this summary of the case, do you believe this patient might have had a better outcome if the care rendered was different?
Expert Witness Response E-004713
This case is routine for any neurologist like myself who sees patients in the hospital and ER. I have seen patients pass away from meningitis in spite of doing a lumbar puncture, correctly diagnosing and treating them, but I have many more (most) who were adequately treated promptly with antibiotics and survived. Based on this summary, it is clear that the patient would have had a better outcome if the care had been rendered differently. Specifically, when the patient presented a third time with difficulty thinking, a central nervous system process should have been considered. Additionally, with an increased white blood cell count, a blood culture and spinal tap was indicated along with empiric antibiotics for sepsis and meningitis. I have had similar cases in the course of my career as a neurologist. Lower back pain or “back pain” alone without fever would not typically lead one to consider meningitis right away. In this relatively young man though, one might consider a complete blood count if one suspected pyelonephritis (kidney or flank pain/tenderness). Still, by the final visit with nausea, vomiting, and altered mental status, he should have had a complete blood count, blood cultures, and a spinal tap along with empiric antibiotics.