A false reassurance

Mr P was a 30-year-old high-earning banker, married with three dependants. He had a one-year history of rheumatoid arthritis, for which he took methotrexate.

His GP took appropriate blood tests frequently and he had experienced no complications since commencing treatment.

He presented to the Emergency Department after noticing a widespread skin rash, which had developed after several days of lethargy and non-specific malaise.

The junior doctor on duty looked at the rash and immediately recognised the “rose petal” papules with erupting vesicles as chicken pox. The doctor established a lack of childhood exposure to the illness and explained the usual course of the disease. Mr P was advised to stay at home, take paracetamol and use calamine lotion for the rash. Mr P did not mention his immunosuppressant treatment and the doctor, satisfied with the diagnosis in a young, healthy-looking patient, did not ask.

The next day, Mr P felt worse so he rang the OOH service and was managed over the phone. The operator, aware that he had been assessed already in hospital, failed to verify his past medical history and current medications. His symptoms remained non-specific and since little had changed from the previous day, he was advised to expect to feel unwell for a few days and told to continue with symptomatic treatment.

The next day, Mr P’s usual GP, Dr Q, saw him with his full medical records. Dr Q was reassured by the fact that he was seen in hospital, and confirmed the diagnosis of chickenpox. He was advised to continue the treatment recommended in hospital and informed that symptoms should resolve within a week. Dr Q considered antiviral treatment in view of the methotrexate but since they were not commenced in hospital during the first 24 hours, he opted to continue the treatment advised by previous practitioners.

Four days after the symptoms started, Mr P collapsed at home. He was taken to hospital and diagnosed with disseminated meningoencephalitis, and failed to respond to further treatment. Despite therapy with high-dose intravenous aciclovir, he eventually died due to multi-organ failure secondary to sepsis.

Mr P’s family made a claim against all parties involved. The case was settled for a high sum, reflecting the needs of his dependants and loss of a high income.

Learning points

• Practitioners must be aware of the complications of being on immunosuppressant medication and remember to enquire about their use – especially in patients with infectious disease. 
• Chicken pox is usually a benign and self-limiting disease. However, healthcare providers should be aware that the majority of complications occur in patients who are immunocompromised and should remember to rule this out by taking a complete history.
• Telephone consultations have their own risks. The patient’s past medical history is usually not available when conducted out of hours. The clinician must obtain a full, detailed history at each different telephone consultation, and this must be recorded.
• When consulting with young, seemingly healthy patients, it is easy to focus on the acute problem and assume there are no chronic health problems if the patient does not volunteer the information. Develop a “safety net”, in which you make general health enquires for every patient you consult.
• It is good practice to see patients with acute problems with a fresh approach. Re-take the history as if no other doctor has ever seen the patient, and draw your own conclusions. Do not unduly depend on, or be misled by, the views of others.