A case where a 38-year-old women died because her pneumonia was not treated early enough
“A medical expert testified on Friday that an internist accused of medical malpractice in the death of a 38-year-old Boonton woman appropriately diagnosed her symptoms as influenza and could not have predicted that the flu would lead to bacterial pneumonia.”

From what I read in the article: On January 18th, 2001, a 38-year old female with body aches and fevers ranging from 100 to 104 degrees presented to a clinic. A chest exam did not reveal any signs of pneumonia (i.e. “lungs were clear”). She was treated conservatively with Motrin.

Three days later, on January 21st, she presented to an emergency room. X-rays then showed pneumonia, and unfortunately, she died on March 12th.

From UptoDate, here are the clinical manifestations and time course of influenza:

Influenza characteristically begins with the abrupt onset of fever, headache, myalgia and malaise, accompanied by manifestations of respiratory tract illness, such as cough and sore throat. In some cases, the onset is so abrupt that patients can recall the precise time at which illness began. However, influenza infections also have a broad spectrum of other presentations which can range from afebrile respiratory illnesses similar to the common cold, to illnesses in which systemic signs and symptoms predominate with relatively little clinical indication of respiratory tract involvement.

Physical findings generally are few in cases of uncomplicated influenza. The patient may appear hot and flushed . . . Physical examination of the chest is generally unremarkable in uncomplicated influenza . . .

Patients with uncomplicated influenza usually gradually improve over two to five days, although the illness may last for one week or more.

Hospitalizations and death are uncommon for women 15 to 44 years of age without comorbid risk factors (4 to 6 per 10,000).

Secondary bacterial pneumonia certainly is a feared complication of influenza. Can it present as quickly as it did in this case (i.e within days)? Possibly:

The hallmark of the clinical presentation in patients with secondary bacterial pneumonia is the exacerbation of fever and respiratory symptoms after initial improvement in the symptoms of acute influenza. Fever may abate for one day or more after two to three days of acute influenza, but, instead of continuing to improve, the patient with secondary bacterial pneumonia relapses with higher fevers, cough, production of purulent sputum, and radiographic evidence of pulmonary infiltrates.

So, how could the defendant have protected herself? With fever, body aches, and a clear lung exam – a clinical diagnosis of influenza would have been reasonable, and the supportive treatment prescribed would have been within standard of care.

But clinical suspicion is dead in American medicine. The physician’s clinical suspicion led to the patient’s death and subsequent lawsuit. You have to test and treat early and often. The defendant would have saved herself the lawsuit had she just, i) ordered a chest X-ray; or ii) prescribed empiric antibiotics regardless.

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