Dx Error: strep turns out to be 'necrotizing fasciitis'

Jason Maude jason.maude at ISABELHEALTHCARE.COM
Tue Apr 11 14:09:04 UTC 2017


I agree the article is poor and gives too little chronological information to read that much in to it.

The question is would or should NF be on a physician’s DDx with this presentation? Generally, I doubt it would be as most would say it’s rare so very unlikely. However, it should be particularly since the lab tests have shown it’s an infection and the child was complaining of what seems undue pain. An infection coupled with disproportionate pain should always make a physician suspect NF.

This is where using a DDx generator can help (we have had a case just like this) as the physician may have thought of NF but have it way down his DDx. If NF then appears prominently in the DDx generator list (see attached example screen shot) it may make him/her reexamine/rethink the patient. There is a synergistic effect in cases like this between the physician and tool.

Regards
Jason

Jason Maude
Founder and CEO Isabel Healthcare
Tel: +44 1428 644886
Tel: +1 703 879 1890
www.isabelhealthcare.com<http://www.isabelhealthcare.com/>


From: Elias Peter <pheski69 at GMAIL.COM>
Reply-To: Society to Improve Diagnosis in Medicine <IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG>, Elias Peter <pheski69 at GMAIL.COM>
Date: Monday, 10 April 2017 14:30
To: "IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG" <IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG>
Subject: Re: [IMPROVEDX] Dx Error: strep turns out to be 'necrotizing fasciitis'

When the patient presented at some (not specified in the news reports) interval after being treated for strep throat, she was reported to have ‘flu symptoms’ which were not specified.  The news reports do not say much about how ill she was at initial presentation, so it is very hard to say what the diagnostic process should have been.

Typical necrotizing fasciitis (strep or otherwise) presents with evidence of a local infection (redness, tenderness, warmth, swelling) following a skin injury and progresses rapidly. Strep is a common pathogen here, but there are others. The only initial clue is unreliable and is pain out of proportion to the injury or local findings. Most often the diagnosis is made when the patient has become fairly sick and it has become apparent that it was not a simple skin infection.

This child does not appear to have had the illness pattern of strep necrotizing fasciitis from a skin injury. In addition, it is not clear that her illness was related to her (+) lab test for strep, as she was apparently diagnosed with 'strep throat' when she had no symptoms, based on what was most likely a false (+) test. (I would consider this a misdiagnosis.) Instead, I am guessing she had what is called strep toxic shock syndrome. If strep gains access to the vascular system (strep bacteremia) it can cause bone and joint infections, pneumonia, abscesses, and very rarely strep toxic shock syndrome. This an extremely rare (less than 1 in 1,000,000) illness with multi-system disease. STTS presents not with a sore throat, but with non-specific symptoms of headache, malaise, fever, myalgia, sometimes cough or abdominal pain. The limb damage is from circulatory collapse, septic emboli, DIC or other complication(s) of the septic process. Again, the initial presentation is non-specific. Initial lab testing *might* have looked worse than the clinical presentation but would not have been specific or pointed to strep toxic shock syndrome.

Based on the limited information available in news reports, I think this is a case where:


  *   The ultimate diagnosis would have been impossible at presentation.
  *   The news reports do not make it possible to determine if the diagnosis would have been made earlier than what happened, or it this would have made a difference.
  *   The downside of testing everyone with mild or non-specific symptoms at presentation in an attempt to screen for unusual or serious illness greatly outweighs the small yield.
  *   The diagnostic and therapeutic course that makes the most sense is to recognize that ALL diagnoses are tentative, to talk this way to patients and caregivers, to have a Plan B in mind if what happens seems not to fit Plan A, and to make sure communication works well. Easier said than done.


Peter



On 2017.04.10, at 8:59 AM, Bob Latino <blatino at reliability.com<mailto:blatino at reliability.com>> wrote:

Thanks Peter

I realize when I post things like this to get the opinions of professional clinicians, I am only providing 'weak' reports.  However, this is true of the general public and what data they get to consume, and shape their opinions about their HC systems.

I also ask these types of questions to understand what goes through a doctor's mind when such a patient presents with symptoms consistent with 'strep' in this case (along with the information a relative had strep as well). When such a conclusion is reached, does that negate the need to look for more rare possibilities?  Would necrotizing fasciitis likely have been determinable at the stage where the physician diagnosed strep, or would something like that develop afterwards?

Thanks for your patience with my questions.
Bob Latino

Robert J. Latino, CEO
Reliability Center, Inc.
1.800.457.0645
blatino at reliability.com<mailto:blatino at reliability.com>
www.reliability.com<http://www.reliability.com>
<image001.jpg><https://www.linkedin.com/company/958495?trk=tyah&trkInfo=clickedVertical%3Acompany%2CclickedEntityId%3A958495%2Cidx%3A1-1-1%2CtarId%3A1464096807851%2Ctas%3Areliability%20center%2C%20inc.>

From: Elias Peter [mailto:pheski69 at GMAIL.COM]
Sent: Monday, April 10, 2017 8:30 AM
To: IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG<mailto:IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG>
Subject: Re: [IMPROVEDX] Dx Error: strep turns out to be 'necrotizing fasciitis'

It is also not clear the patient had a strep infection initially, based on the news reports (a terrible sure of data).

She is reported to have been treated for strep because she had a (+) strep test (the reporting does not specify culture or rapid strep) although was asymptomatic at the time. The strep test was done apparently because a relative had a strep throat.

If this reporting is true, the initial errors were diagnosing and treating her for strep throat.

Caveat: I do not have access to the actual case report.

Peter Elias, MD


On 2017.04.09, at 10:22 PM, Tom Benzoni <benzonit at GMAIL.COM<mailto:benzonit at GMAIL.COM>> wrote:

It looks like it was initially considered and diagnosed, according to this story.
tom

On Sun, Apr 9, 2017 at 6:35 PM, Bob Latino <blatino at reliability.com<mailto:blatino at reliability.com>> wrote:
Is this a case where 'necrotizing fasciitis' is so rare it would not have been initially considered?  Should it have initially considered?

http://ijr.com/2017/04/841212-6-year-old-complained-sore-throat-infection-spread-doctors-remove-leg/?utm_source=Facebook&utm_medium=Owned&utm_term=ijamerica&utm_campaign=ods&utm_content=Family
Sent from my iPhone

On Apr 9, 2017, at 7:20 PM, Bob Swerlick <rswerli at GMAIL.COM<mailto:rswerli at GMAIL.COM>> wrote:
We have a single payer system closer to home, that being the VA health system. I do not know of any data suggesting that the frequency of diagnostic error is any better or worse within the VA. I also cannot think of any reason why a single payer system would be better at diagnostic work. Perhaps someone who suggested this could provide me with their train of thought?

Bob Swerlick

On Sun, Apr 9, 2017 at 4:33 PM, Peggy Zuckerman <peggyzuckerman at gmail.com<mailto:peggyzuckerman at gmail.com>> wrote:
Re the question if a country with a single-payer system automatically grants patients better care and better outcomes, the real question to be posed is what measures are used to do so.

In my kidney cancer world which encompasses many patients in the US, Canada and the UK, I know of many errors in diagnosis in each of them.  Much of those errors derive from the simple lack of expertise by a mix of doctors. Primary care docs don't consider the symptoms which can be reported over a long period of time, whether serious back aches (flank pain is classic symptom--but what patient uses the term "flank pain"?), anemia, or unexplained weight loss. Urologists who may operate to remove a tumor often do not complete the diagnosis with CTs and /or bone scans, and reassure the patient, "I got it all", yet they do not search out the non-localized metastases.  When that patient finally is sent to an oncologist, if ever, the oncologist may not have any idea of what to do, and may simply apply the 25 year old treatment--nothing--or use the latest newly approved drug, but with little understanding of the disease and those treatments.

All of these mistakes happen in all three of these countries.  In Canada, the province in which one lives makes a difference as to the medicines and/ior specialists available. Similar in the UK, with Scotland having far higher death rates from cancer.  The measures of treatment for diagnosed cancer patients is mandated to start at 31 days.  Yet extending out tests which diagnose, including those which should have been done simultaneously gives a reset of the clock.  So treatment does not begin in 31 days, but 31 days after 90 days of delayed testing.

Peggy z

Peggy Zuckerman
www.peggyRCC.com<http://www.peggyrcc.com/>

On Sun, Apr 9, 2017 at 8:34 AM, Goldman, Bruce I <Bruce_Goldman at urmc.rochester.edu<mailto:Bruce_Goldman at urmc.rochester.edu>> wrote:
Lab accreditation is supposed to assure autopsy quality, but diagnostic accuracy is not a directly evaluated parameter-it is a really important question, especially since the primary responsibility for an autopsy is often given to a trainee.

-----Original Message-----
From: Traian Mihaescu [mailto:traian at MIHAESCU.EU<mailto:traian at MIHAESCU.EU>]
Sent: Friday, April 07, 2017 3:08 PM
To: IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG<mailto:IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG>
Subject: Re: [IMPROVEDX] The Value of a Second Opinion at the Mayo Clinic

"An autopsy can reveal clinically significant diagnoses missed before death"..but, are there any data about diagnostic errors in autopsy studies?

Traian Mihaescu, MD
Clinic of Pulmonary Diseases
Iasi, Romania
https://urldefense.proofpoint.com/v2/url?u=http-3A__www.ispro.ro&d=DQIFaQ&c=4sF48jRmVAe_CH-k9mXYXEGfSnM3bY53YSKuLUQRxhA&r=-7e4riqIt55t2dJrgCurSOAaZ9YfqnMopB2FIHXKJzY&m=SfdVEuqtJnQTI9F56tW2vYSsx863VpoqEHsQWBArk50&s=JH19pC8Ck33mexsqm9i2BBQPVIguU2vYL2CuhXd2xqY&e=

> The gold standard used to be autopsy. Unfortunately, the rate too low
> to be of much use today.
>
> Harry B. Burke, MD, PhD
>
> Chief, Section of Safety and Quality
>
>
> Associate Professor of Medicine
>
> Department of Medicine
>
> F. Edward Hébert School of Medicine
>
> Uniformed Services University of the Health Sciences
>
>
>> On Apr 5, 2017, at 12:45 PM, Mark Graber
>> <Mark.Graber at IMPROVEDIAGNOSIS.ORG<mailto:Mark.Graber at IMPROVEDIAGNOSIS.ORG>> wrote:
>>
>> Thanks Bridget for this KEY question.  There are indeed a few studies
>> that have done longer-term follow up of patients to determine whether
>> the second opinion was correct (referenced in the attached review
>> article) and you won’t be surprised to know that in a fraction of
>> these cases (around 10%) the original diagnosis was correct, or even
>> something not yet considered.  These long-term follow-up studies are
>> difficult to conduct but very valuable.
>>
>> Your comments also touch on another big problem in our field – what
>> is the gold standard?  There is a great deal of uncertainty even at
>> this level, given that biopsy and autopsy results are not always definitive.
>>
>> Mark
>>
>> Mark L Graber MD FACP
>> President, SIDM
>> Senior Fellow, RTI International
>> Professor Emeritus, Stony Brook University
>>
>>
>>
>>
>>
>> From: Bridget Kane <kaneb at tcd.ie<mailto:kaneb at tcd.ie> <mailto:kaneb at tcd.ie<mailto:kaneb at tcd.ie>>>
>> Date: Wednesday, April 5, 2017 at 12:49 AM
>> To: Listserv ImproveDx <IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG<mailto:IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG>
>> <mailto:IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG<mailto:IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG>>>,
>> "mark.graber at improvediagnosis.org<mailto:mark.graber at improvediagnosis.org>
>> <mailto:mark.graber at improvediagnosis.org<mailto:mark.graber at improvediagnosis.org>>"
>> <Mark.Graber at Improvediagnosis.org<mailto:Mark.Graber at Improvediagnosis.org>>>
>> <mailto:Mark.Graber at Improvediagnosis.org<mailto:Mark.Graber at Improvediagnosis.org>>>
>> Subject: Re: [IMPROVEDX] The Value of a Second Opinion at the Mayo
>> Clinic
>>
>> One of the questions for me is “are we assuming that the second
>> opinion is the gold standard?”
>> Or how can we identify the truth, i.e. the correct diagnosis?
>>
>> Is there a stronger placebo effect following a second opinion, I wonder?
>>
>> Does anyone have any research on this, by chance?
>>
>> Thanks
>>
>> Bridget
>> On 4 Apr 2017, at 16:02, Mark Graber <Mark.Graber at IMPROVEDIAGNOSIS.ORG<mailto:Mark.Graber at IMPROVEDIAGNOSIS.ORG>>> <mailto:Mark.Graber at IMPROVEDIAGNOSIS.ORG<mailto:Mark.Graber at IMPROVEDIAGNOSIS.ORG>>> wrote:
>>
>> Just coming out – this study from the Mayo Clinic
>> <https://urldefense.proofpoint.com/v2/url?u=https-3A__www.washingtonp
>> ost.com<http://ost.com/>_national_health-2Dscience_20-2Dpercent-2Dof-2Dpatients-2Dwith
>> -2Dserious-2Dconditions-2Dare-2Dfirst-2Dmisdiagnosed-2Dstudy-2Dsays_2
>> 017_04_03_e386982a-2D189f-2D11e7-2D9887-2D1a5314b56a08-5Fstory.html-3
>> Futm-5Fterm-3D.11d4a1346899&d=DQIFaQ&c=4sF48jRmVAe_CH-k9mXYXEGfSnM3bY
>> 53YSKuLUQRxhA&r=-7e4riqIt55t2dJrgCurSOAaZ9YfqnMopB2FIHXKJzY&m=SfdVEuq
>> tJnQTI9F56tW2vYSsx863VpoqEHsQWBArk50&s=A37cxdq81T3k3BLLvzRBM2uveYtXpG
>> ll56AjR0LJ4Ns&e= > finds that 20% of referred patients end up with a very different diagnosis.  The findings are very similar to the results from the second opinion program at Best Doctors, as referenced in the Mayo Clinic article.  In both cases, however, these are not randomly selected patients being studied – they are patients who were concerned enough about their initial diagnosis (or lack thereof) to seek out the second opinion.
>>
>> Mark
>>
>> Mark L Graber MD FACP
>> President, SIDM
>> Senior Fellow, RTI International
>> Professor Emeritus, Stony Brook University <image001.png>
>>
>>
>>
>> Address messages to: IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG<mailto:IMPROVEDX at LIST.IMPROVEDIAGNOSIS.ORG>
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