How does a healthy 24 yo get a brain abscess?

How does a doctor miss it? Is it negligence?

Facts: A 24 yo male is taken to the ED by his parents after “passing out” and “unconscious for a few seconds." He has been ill for 3 days with abdominal px, fever, diarrhea and vomiting. His father had just helped him out of bed when his limbs began “shaking.” His father believes his son is dehydrated. The triage nurse records the event as a “seizure” lasting 7 minutes (documented on his later return to the ED as “10 minutes of blank stare.") ROS reveals back px, myalgias and weakness but no HA or ear px. No PH of substance abuse. VS are normal with a T of 97.3 (1 hour after ibuprofen.) Exam 30 minutes after the event records him as being “A & O” but “tired appearing” and “not appearing post-ictal.” He has “severe eczema especially on the hands and arms.” Speech, behavior and remainder of exam is normal and GCS is 15. WBC is 22,910 with 82% polys and 8% bands with 2+ toxic granulation and 1+ Dohle bodies. Urine specific gravity is 1.02 w/ ketones. UDS is negative. A CT abdomen w/ IV contrast is normal. The record mentions an ongoing community outbreak of gastroenteritis with "6 patients currently in the ED with similar sx." He is given Zofran for nausea, Norflex, Toradol 15 mg and MS 2 mg for back px, plus 3 L of IV NS. He is able to walk independently to the BR before being discharged "improved" w/ a dx of gastroenteritis. Sixteen hours later he has a grand mal seizure and returns to the ED via EMS, comatose with a GCS of 3. A second EP elicits a hx of recurrent ear infections, 5 sets of PE tubes and some recent drainage from the L ear, confirmed on exam as a "brown drainage." A CT scan shows a L temporal mass, cerebral edema and possible early herniation. He is transferred to a tertiary care hospital where an MRI reveals bilateral mastoiditis with bony erosion. He undergoes surgery but dies post-op due to brain herniation.
Plaintiff: You paid no attention to the high WBC w/ a left shift. You minimized the seizure. You never asked about his ears and didn’t examine them. Fever and a seizure in a healthy 24 yo warrants a CT scan of the brain.
Defense: The ED doc considered the evidence for a seizure (“not post-ictal”) and reasoned that dehydration and orthostatic hypotension explained a syncopal episode with limb shaking. A thorough differential dx and the high WBC was addressed in the MDM. Not imaging the brain was a reasonable judgment call based on the lack of headache or other neurological signs or symptoms. The elevated WBC could be due to dehydration. There is no negligence, as the documentation supports reasonable judgment calls.
Result: An attorney is consulted and the records were reviewed by an emergency medicine expert. The expert identified Issues that would likely be raised by the defense and their experts, e.g., “judgment vs. negligence” and "causation," i.e., the likelihood of a better outcome with earlier surgery. A battle of multiple experts (EM, ENT, neurosurgery, infectious disease, nursing) over several years at unpredictable expense was inevitable, making the case too risky for the attorney's firm to pursue. The family was advised that a larger firm with deeper pockets and more risk tolerance might consider pursuing the case.
Takeaways:
* Read the nursing notes. The word "seizure" should capture one's attention.
* Document any discrepancies between your own history/exam and that of the nurse(s). Discuss them with the nurse(s). EM is a "team sport." Include your team.
* Pay attention to lab values, especially bandemia. A CRP/ESR could have been helpful in this case.
* Acute on chronic ear infection was the likely source of the brain abscess (and mastoiditis), yet the ENT hx and exam were incomplete on the first ED visit.
* Good MDM is a defense against a malpractice lawsuit. One can make a wrong judgment that is not negligent, but one’s reasoning must be documented. In this case the words "post ictal" play a significant role, indicating the EP was aware of a possible seizure.
* Only 70% of patients with a brain abscess have a headache.
* The triad of fever, headache and focal neurologic deficit occurs in less than half of patients. This patient had none of these.
* The clinical course ranges from indolent to fulminant. Symptoms are present for 2 weeks or less in about 2/3 of patients.
Reference: Brain Abscess Clinical Presentation. Brook I. Medscape eMedicine. Updated: Oct 27, 2017.