Meningitis misdiagnosed in college student, with tragic consequences

<p>This story, from today's Philadelphia Inquirer, is extremely tragic and frightening. A student went to the emergency room (of the Hospital of the University of Pennsylvania, renowned hospital) with meningitis symptoms and was sent home after being told she had a virus and would be fine. A few days later, she died of meningitis, which apparently could have been treated successfully if she had been properly diagnosed. The student did everything she should have done, but the doctors messed up. I can't imagine how heartbroken her parents and family must be.... </p>

<p><a href="http://www.philly.com/inquirer/breaking/news_breaking/20071002_Lawyer__Student_diagnosis_wrong.html%5B/url%5D"&gt;http://www.philly.com/inquirer/breaking/news_breaking/20071002_Lawyer__Student_diagnosis_wrong.html&lt;/a&gt;&lt;/p>

<p>Lawyer: Student diagnosis 'wrong'
The Penn sophomore died after being told she had an infection that would clear up.
By Marie McCullough</p>

<p>Inquirer Staff Writer</p>

<p>Anne Ryan and her brother Jed were relieved when an emergency room doctor at the Hospital of the University of Pennsylvania said she had a viral infection that should soon clear up.</p>

<p>The doctor sent Ryan, a 19-year-old sophomore at Penn, home with a form letter certifying that she could go back to classes two days later, on Sept. 8.</p>

<p>Instead, on Sept. 8 she was back in the emergency room, critically ill. She died the next day of meningococcal meningitis, a bacterial infection.</p>

<p>Thomas Kline, a Philadelphia lawyer hired by Ryan's family to investigate what happened, said, "The one thing I can tell you without equivocation is the diagnosis was wrong."</p>

<p>In a statement, Penn officials maintained that Ryan was "cared for in a timely fashion with appropriate medical measures by a dedicated and highly skilled team of health-care professionals."</p>

<p>But the death of the young woman - an Arabic and environmental studies major from Albion, Pa., who had appeared on the cover of the Penn student fashion magazine and in a student fashion show - has raised questions about the appropriateness of her care, the Philadelphia Daily News reported Saturday.</p>

<p>Ryan initially went to the emergency room on Sept. 6 complaining of fever, severe headache, neck pain and nausea. Because these are classic symptoms of meningitis - a rare infection of the fluid in the spinal cord and brain - HUP doctors ordered the standard diagnostic test, an analysis of fluid tapped from the spinal cord.</p>

<p>The hospital's release form shows that just before midnight, she was discharged with an anti-nausea medication and no other treatment. Jed Ryan, a Penn alumnus, took his sister back to his Philadelphia apartment to look after her until she felt up to going back to campus.</p>

<p>"They were relieved," Kline said. "The discharge paper said, 'You have a viral infection. Lumbar puncture results did not reveal any evidence of brain infection.' "</p>

<p>Meningitis can be caused by a viral or bacterial infection. The viral form is usually less severe and goes away without specific treatment, according to the U.S. Centers for Disease Control and Prevention (CDC).</p>

<p>Bacterial meningitis, in contrast, is potentially deadly, and early treatment is crucial.</p>

<p>It "can be treated with a number of effective antibiotics," says the CDC. "It is important, however, that treatment be started early in the course of the disease."</p>

<p>With appropriate antibiotic treatment, the risk of dying is less than 15 percent, the CDC adds.</p>

<p>Tom Clark, a CDC epidemiologist and meningitis expert, said that when bacterial meningitis is suspected, antibiotics are typically started before a final diagnosis is made because rapid diagnostic tests of the spinal fluid are not definitive. Rapid analysis includes counting white blood cells, measuring glucose and protein levels, and staining the fluid to look for bacteria.</p>

<p>The best test, which involves culturing the fluid to try to grow the bacteria, takes about 48 hours, Clark said.</p>

<p>"The usual practice, certainly if you suspect bacterial meningitis, is to treat empirically. Don't wait until the culture results are final," Clark said.</p>

<p>Each year in the United States there are an estimated 2,800 cases of bacterial meningococcal disease, including meningitis, Clark said. The disease is contagious, but is spread only through close, prolonged contact.</p>

<p>Vaccines are available that protect against some types of bacteria that cause meningitis, but these vaccines are not completely protective.</p>

<p>Kline said Ryan had "some meningococcal inoculation," but he did not yet have the specifics. He would not say what type of bacteria caused her meningitis, although an autopsy has identified it.</p>

<p>Following Ryan's death, Penn offered antibiotics to people who had had close contact with her, and created a Web site to educate students about meningococcal disease.</p>

<p>Kline said he was waiting to get the rest of her hospital records. "Penn has promised to cooperate," he said.</p>

<p>This is so tragic.
When my son received his vaccine from the student health center, the doctor was very clear that it would only protect him from a couple of the most common forms of the disease. I guess this was to make sure he didn't let his gurard down, or assume that he couldn't get meningitis just because he had been innoculated.<br>
I wish they would release more information about the specific type of bacteria that caused Ryan's case, and if it was one that the current vaccine covers.</p>

<p>I think everyone assumes it wasn't. The vaccine is mandatory in Pennsylvania; she could not have matriculated at Penn last year without it.</p>

<p>Our pediatrician told me that the vaccine does not provise immunity against a strain that represents about 30% of meningococcal infections. So it's not a needle-in-a-haystack kind of situation.</p>

<p>This is really sad, though -- that she was at the hospital in plenty of time for effective treatment, and they dropped the ball.</p>

<p>According to the CDC expert quoted, it is standard operating procedure to give antibiotics to anyone with those symptoms until the results of the 48 hour test come back, even if the rapid test is negative. That is what is so disturbing about this story - the doctors didn't have to do any thinking on their own, they just needed to follow a standard protocol for this situation, and they didn't do it.</p>

<p>Haven't you learned anything from the Duke lacrosse incident? This is a PLAINTIFFS' lawyer's version of what happened. Perhaps there were mistakes made, but don't jump to that conclusion based on the interpretation by this lawyer.</p>

<p>If this is true, it's a heartbreaking followup to this story. </p>

<p>There are some students that can be excused from taking the vaccine - with a doctor's note if it is contraindicated for medical reasons or for religious reasons with complete documentation of that (they don't make it easy, to get this exception , in other words). I had wondered if there was a chance that Ryan fell into either category, but apparently not.</p>

<p>MOWC. I have to admit that I thought of your point before posting, but the facts reported here (if accurate) seem much more clearcut than in the Duke case.</p>

<p>Bacterial meningitis with normal LP (lumbar puncture)findings is very rare. Given the advent of superbugs and resistant organisms, it has become standard of care to not treat with antibiotics "just in case" when the LP is negative and the culture is pending. </p>

<p>This is tragic. Even at the best of institutions, with the best of care, bacterial meningitis can be fulminate and deadly. It would help to know if this child received the vaccine or not (you can easily sign a waiver), and if the bacteria would even have been sensitive to what she "could" have been put on while waiting for the culture results. </p>

<p>Had this been my D and she called with a)a prescription for antibiotics, b) these same symptoms, and c)a normal preliminary LP result ----I would have told her not to take antibiotics :(. Scary.</p>

<p>Since they're quoting plaintiff's attorney, I can almost guarantee you that the facts are not "accurate" but are "spun" - that's the lawyer's job (and I say that as a lawyer). You'd get a different set of facts, or at least a different "spin" if the article were quoting the hospital's or the doctor's lawyer.</p>

<p>Sunnyflorida - You are a physician and are thus much more knowledgeable about this than I am. I naively took the article at face value, especially the part where a CDC expert said that antibiotics are typically started even if the rapid test is negative. I assumed that a CDC expert on meningitis would be accurate on this question, and would not have any motive to "spin" the facts or provide misinformation. I guess I was wrong about this???</p>

<p>Thanks for that background sunnyflorida.</p>

<p>I thought I was going to read that they never did a spinal tap, missing the diagnosis, but they did one. So what's really puzzling to me, is that the spinal fluid should have shown some white cells. It's common knowledge medically that the patient is given immediate IV antibiotics and admitted until the cultures are back with any case of meningitis. I can't imagine the ER sending this poor girl out if she had ANY cells in her fluid, even if the stain for bacteria was negative. This article implies the spinal fluid was completely clear of CELLS, and that is what is highly atypical. I am amazed and horrified at this outcome for this poor girl and family! Something in this story doesn't fit, though- so as MOWC said- there may be more facts- maybe a lab error even, which is also a horrifying thought. </p>

<p>Here's my personal story (as a mom and MD)-</p>

<p>When my dd was a new freshman in HS, she went to the school nurse with a bad headache and feeling ill. This is a very stoic kid who never presented to a school nurse in her life. The nurse pretty much dismissed her complaints, but my d insisted that she call me. I was at that school in a shot, took one look at her, saw that she was febrile with a rash and stiff neck besides the headache, and picked her up and RAN to my car to take her to the ER. I knew I would get her there faster than waiting for the ambulance. On route, I called the ER, an anesthesiologist to get prepared for the spinal tap, and the pharmacy to get the IV antibiotics ready to infuse immediately. I was never so scared in my life, and I am really trained for emergencies, but when it's your kid...Anyway, I hate to admit that I ran red lights with horn beeping, and arrived in record time. Long story short- she did have meningitis (many white cells in her spinal fluid), got her antibiotics and is a sophomore in college today. It turned out to be viral, and she was back in school in a week. But it COULD have been meningococcal.</p>

<p>My dd has told me that it was the first time she was glad her mom was a doctor.</p>

<p>My heart BREAKS for this poor girl's family!</p>

<p>This is what the Merck Manual (Home Edition) online has to say about this question. It indicates that if the person seems ill, antibiotics should be started immediately, while the culture is being done. If the culture results show that a different antibiotic is needed, the medicine should be switched. This advice seems to agree with the CDC expert quoted in the article.</p>

<p><a href="http://www.merck.com/mmhe/sec06/ch089/ch089b.html%5B/url%5D"&gt;http://www.merck.com/mmhe/sec06/ch089/ch089b.html&lt;/a&gt;&lt;/p>

<p>Quote from website:</p>

<p>When doctors suspect meningitis, they must quickly decide whether to treat it immediately or to first perform procedures to determine the specific cause. If the person appears ill, one or more antibiotics are given immediately, before results of diagnostic procedures are known. If the person does not appear ill, treatment may be delayed until procedures are performed to determine whether meningitis is due to bacteria, a virus, another organism, or a noninfectious condition (such as an autoimmune reaction or use of certain drugs).</p>

<p>Usually, a spinal tap (lumbar puncture (see Diagnosis of Brain, Spinal Cord, and Nerve Disorders:Procedures) is performed to diagnose meningitis and determine its cause. A thin needle is inserted between two vertebrae in the lower spine to withdraw a sample of cerebrospinal fluid. Sugar and protein levels and the number and type of white blood cells in the fluid are determined; this information helps doctors distinguish between bacterial and viral infections. Doctors examine the fluid under a microscope to check for and identify bacteria. If they do not see any bacteria, doctors perform other tests that can rapidly identify certain bacteria, such as Neisseria meningitidis and Streptococcus pneumoniae. These tests include analysis of the cerebrospinal fluid for evidence of antibodies against the bacteria and polymerase chain reaction (PCR) techniques, which cause DNA to make copies of itself.</p>

<p>A sample of the cerebrospinal fluid is sent to a laboratory, where the bacteria can be grown (cultured) and identified. The bacteria can be tested for susceptibility to treatment with different antibiotics, so that the antibiotic therapy that was started immediately can be adjusted if necessary.</p>

<p>I thank G-d that your daughter is ok, Galwaymom!</p>

<p>Last weekend, my son was sick (severe headache, neuro symptoms and 102 fever). He tried to sleep it off because he wanted to go to the football game (he didn't go). Sunday morning, he headed off to the school health center. The doctor examined him and sent him off to the ER where they did tests & put him on intravenous antibiotics, eventually sending him back to the dorm (he insisted) with an antibiotics prescription. It wasn't meningitis but pneumonia (he's had both before and knows the routine).</p>

<p>It's scary when our kids are far away and want to be independent. My son didn't tell us he was sick. He simply texted asking for the name of a neurologist in Providence - that was our "clue." I was happy to learn 2 things. His health center had doctors available on weekends (Sunday). They knew how to deal with a "stupid" college student who showed up without his wallet (so they gave him cab fare vouchers). The hospital treated him, despite having no insurance card, license, etc - just his college id. The hospital asked him to have us call in his info that night. And the school had his prescription filled for him and delivered to campus.</p>

<p>Here is an excerpt from a 2004 article entitled "Practice Guidelines for the Management of Bacterial Meningitis" from Clinical Infectious Diseases 2004;39:1267-1284. <a href="http://www.journals.uchicago.edu/CID/journal/issues/v39n9/34796/34796.text.html?erFrom=-379514755395364853Guest#sc2.2%5B/url%5D"&gt;http://www.journals.uchicago.edu/CID/journal/issues/v39n9/34796/34796.text.html?erFrom=-379514755395364853Guest#sc2.2&lt;/a&gt;&lt;/p>

<p>Of interest are the sections "What Specific CSF Diagnostic Tests Should Be Used to Determine the Bacterial Etiology of Meningitis?" and "What Laboratory Testing May Be Helpful in Distinguishing Bacterial from Viral Meningitis?"

[quote]
In patients with CSF findings consistent with a diagnosis of bacterial meningitis, but in whom the CSF Gram stain and culture results are negative, there is no test that is definitive for or against the diagnosis of bacterial meningitis. A combination of test results, however, may permit an accurate prediction of the likelihood of bacterial versus viral meningitis. In one analysis of 422 patients with acute bacterial or viral meningitis, a CSF glucose concentration of <34 mg/dL, a ratio of CSF to blood glucose of <0.23, a CSF protein concentration of >220 mg/dL, a CSF leukocyte count of >2000 leukocytes/mm3, or a CSF neutrophil count of >1180 neutrophils/mm3 were individual predictors of bacterial, rather than viral, meningitis, with ⩾99% certainty [20]. This model was validated in one retrospective review of adult patients with bacterial or viral meningitis [21], although proof of the clinical utility of this model will require a prospective application. This model, however, should not be used to make clinical decisions regarding the initiation of antimicrobial therapy in individual patients with meningitis.

[/quote]
</p>

<p>But ER docs don't play guessing games with this diagnosis when the spinal fluid shows any abnormal results, and I can't imagine a patient being sent out of the ER with ANY EVIDENCE of ANY KIND of meningitis in the spinal fluid. The spinal fluid results in early bacterial meningitis often looks like the spinal fluid in viral meningitis, but there are still abnormal cells in the fluid, and so one treats as if it IS bacterial until the culture results return days later. </p>

<p>The news article of this poor student implies that there WAS evidence of it, which I take to mean that there were cells, etc. in the fluid, and she was sent home anyway- but I suspect she was sent out because the results of the fluid were reported from the lab as totally NORMAL. This is the key piece of information unavailable from the news so far.</p>

<p>Tragic.</p>

<p>Agreed.</p>

<p>Of course, we don't have the actual results of the CSF glucose, protein leukocytes, or the ratios etc. Nor do we have the Gram Stain. It remains to be seen if she was sent home with no antibiotics and a CSF that was negative for glucose, protein and WBC's or not. It almost sounds as if this was the case, which is why is is scary.</p>

<p>Again, if my D called me and said she had an LP, and her CSF showed no glucose, no protein and no WBC's, I would have told her she didn't need antibiotics. That's all I am saying. </p>

<p>I recall a similar story when Jim Hensen (Muppet creator) died of overwhelming sepsis/toxic shock from a Strep infection. As I recall, he was treated for a viral infection and sent home without antibiotics. He presented not 36 hours later near death. </p>

<p>You can die from not receiving antibiotics, you can die of anaphylaxis or other complications (C. difficile) from receiving antibiotics, you can die as a result of resistant bacterial even while on antibiotics as a result of the overuse of antibiotics (MRSA). </p>

<p>It is not always as straight-forward as it looks.</p>

<p>Now, if her LP was positive, and she was mistakenly sent home without proper treatment due to gross error, it should be handled like the Duke transplant case and the institution should come out publicly immediately with an apology and an explanation of a plan for this to never happen again. </p>

<p>This could certainly be gross negligence. This could also be a case where the LP showed no evidence of meningitis. We just don't have all the facts.</p>

<p>Absolutely, sunnyflorida. Well said.</p>

<p>For those who are not clinical doctors, try to hold back judgement on this one until all the information is out there, especially the medical record notes.</p>

<p>I can easily think of the following scenario that would support a well trained and caring ER physician letting this young girl go home from the ER (and any one who has suspected bacterial meningitis that presents to an ER does not go home on oral antibiotics - that person is admitted for IV treatment, and closely observed in or near the ICU for possible developing complications).</p>

<p>Let's suppose this unfortunate girl presented with a history of about 6hrs of steady high fevers, mild neck stiffness and nausea, and maybe even one emesis. But on physical exam, there is no photophobia, the neck stiffness seems more muscular in origin, and meningeal signs on physical exam were questionable. Let's also suppose that she did not look "toxic". The physician decided to initiate a r/o meningitis work-up, which by the time you start and you get your results back (including probably blood tests) will take many hours affording the ER team the observation time to watch this girl. Suppose the CBC returned normal with a relatively unremarkable differential (which would be probable, even with possibly a lymphocyte predominence) and the CSF studies showed a "bloody" tap with the CSF pleocytosis having an appropriate neutrophil/lymphocyte ratio that's similar to the blood. In addition, the CSF glucose was not depressed at all in relation to the CSF protein, and absolutely no bacteria seen on the CSF gram stain. Combined with all this, the young girl had a meningococcal vaccine just prior to college entry, and there is a "viral syndrome" type of an illness circulating around that area. I can reasonably imagine the ER physician saying to her that "you probably have a viral illness and you should be able to return to classes in a couple of days...but, if your symptoms of headache or nausea worsen at all, or something new developes, you need to see your private doctor or come back to this ER immediately."</p>

<p>If the above was the scenario, then I feel it would be unjust to crucify this ER doctor as doing malpractice. The bottom line is that we don't know until the actual medical record containing the doctor's and nurse's notes are seen. It is a very unfortunate situation, and everyone who is involved with this student, family and medical staff, I'm sure is going through an inner hell wondering what could have been done differently to have prevented this.</p>

<p>I tell the parents of my patients that meningococcal meningitis scares the daylights out of me, because it can fool everyone early in its course. And if untreated, particularly with high dose IV antibiotics, your child will be dead. Give this ER doctor a break, and this hospital ER a break, until all of the information is released to the public for a more clear analysis.</p>

<p>jack</p>