On 10/6/2015, a patient presented to the emergency department with pain in the back of his neck, ongoing headache, and intermittent fever over the past two weeks.  The patient had a recent history of visual and auditory hallucinations.  The patient was also receiving interferon therapy.

The patient was febrile, tachycardic, and had classic findings of meningitis.  The ED physician ordered for the patient to undergo a lumbar puncture for collection of cerebrospinal fluid (CSF) to confirm or exclude conditions, including meningitis or a subarachnoid hemorrhage.  The patient’s CSF indicated an elevated white blood cell count with zero organisms detected.  The ED physician attributed these results and symptoms to viral meningitis.  The CSF results noted that the fluid was cloudy and had xanthochromia, but these findings were not acknowledged by the ED physician.

The ED physician did not rule out the possibility of a head bleed or bacterial meningitis and did not administer antibiotics prior to discharging the patient home after also obtaining blood cultures.  The patient was immunocompromised by interferon therapy with pancytopenia, which can cause atypical responses to infections.  Xanthochromia and cloudiness of the CSF could be caused by bacterial meningitis.

The blood cultures came back positive for Staphylococcus aureus infection within twenty-four hours.  The patient was called back to the hospital and admitted for treatment.  Subsequently, the patient was diagnosed with a cervical spine epidural abscess and suffered permanent neurologic impairment.

The Commission stipulated the ED physician reimburse costs to the Commission, complete 6 hours of continuing education on the analysis of cerebrospinal fluid, implications of xanthochromia, and the differential diagnosis of meningitis in patients with headaches, and write and submit a paper of at least 1000 words, plus bibliography, addressing the analysis of cerebrospinal fluid, implications of xanthochromia, and the differential diagnosis of meningitis in patients with headaches.

State: Washington

Date: May 2016

Specialty: Emergency Medicine, Internal Medicine

Symptom: Fever, Headache, Head/Neck Pain

Diagnosis: Meningitis/Encephalitis

Medical Error: Diagnostic error

Significant Outcome: Permanent Loss Of Functional Status Or Organ, Hospital Bounce Back

Case Rating: 5

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