A healthy forty-five year-old man awoke to find he had trouble speaking. At the emergency department he underwent an urgent CT scan of his brain showing multiple masses in his brain the largest of which was about an inch in diameter. A chest x-ray showed a spot in his lung, compatible with either infection or a tumor, and he was given the presumptive diagnosis of lung cancer and brain metastases. He had never smoked and had no history of asbestos exposure. He had no fever.
He was admitted to the hospital and started on large doses of steroids to reduce the swelling in his brain. His speech improved. A lung biopsy, done to confirm the presence of malignancy, showed only mild inflammation without cancer cells. Repeat biopsy showed the same thing. He was discharged with instructions to taper his steroids and follow up with the oncologist who had seen him in the hospital.
Shortly after discharge his speech grew dramatically worse and he developed a fever. He was readmitted to the hospital. Repeat CT scan showed dramatic enlargement of the brain lesions (see attached picture showing several CT slices of his brain). He underwent emergency craniotomy (exploratory brain surgery) and was found to have multiple brain abscesses, with pus coming from several of the lesions. He was placed on large doses of antibiotics and improved, but his speech never returned. He is now totally incapacitated by his inability to talk. His family sued the hospital and all of the doctors involved in his care, including the oncologist who saw him once during his first admission.
At trial, the experts trying to help the hospital and doctors testified that this case represented the “perfect storm” of misdiagnosis: a spot on the lung with multiple brain lesions is lung cancer almost 100% of the time. Brain abscesses are rare and typically occur in people with extremely damaged immune systems, e.g., with AIDS or following ultra-high-dose chemotherapy and bone marrow transplantation. They are almost never seen in previously healthy people. The jury was unconvinced and awarded the man $3.5 million; the oncologist was exonerated and no money was paid on his behalf.
Is there a smoking gun in this case? Could something cleverer have been done to avoid this catastrophe? I appeared at trial on behalf of the oncologist and testified that he had done nothing wrong because he was waiting for a tissue diagnosis and had made no other contribution to the man’s care. Prior to the trial I had reviewed the medical record in detail but had never seen the actual x-rays, relying instead on the reports generated by the consulting radiologist, as had all the treating physicians. On cross examination the plaintiff’s attorney put up the CT scans for me to look at. I thought to myself, “Oh my! These spots do not look like metastases; they look like abscesses.” There were multiple cavitating lesions with thick-walled capsules, much more like infection than cancer. Fortunately the lawyer did not ask me what I thought of these; I would have been at a loss for words.
What is the lesson to be learned? When a diagnosis is not nailed down and all the facts do not line up to support a given illness with a high degree of certainty, and where life-altering complications are involved, go back to the primary source documents including history, physical findings, lab tests and x-rays and have another look. Furthermore, this man was sent home without a diagnosis on strong medications without a clear-cut strategy in place. If the doctor can’t figure out what is wrong with his patient he has a duty to find another doctor who can. Perhaps this man should have been referred to a tertiary-care center or university hospital. The institution in which he was hospitalized is part of a large health-care system at whose center is a world-famous academic teaching hospital. Had that been done perhaps this catastrophe could have been prevented.
Dr. James Stark is the founder of StarkOncology, where he practiced Oncology in Hampton Roads for thirty-four years. He is now a health-care consultant specializing in topics such as breast cancer, colon cancer, lung cancer, chemotherapy complications, and failure to screen. In addition to this new venture he continues to serve as Professor of Medicine at Eastern Virginia Medical School.