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Abscess or tumour

01 January 2008

Mrs A, a 50-year-old bus driver, presented to A&E with a short history of headache, vomiting and fever. Her family had noticed a recent change in her behaviour and she had been having difficulty coping at work over the previous few days. On examination, she was irritable and mildly pyrexial. The SpR in A&E described “blurred discs” on fundoscopy but otherwise routine clinical examination was normal. Her serum CRP was elevated and there was a slight leukocytosis on the FBC. Other blood tests, a chest x-ray and an ECG were normal.

Mrs A’s husband was just getting over a bout of ‘flu and initially she was thought to have a viral illness. However, in view of the severity of her headache and the abnormal fundoscopy, she was referred for a CT scan of the head. This was carried out later that evening by the on-call radiologist Dr S. He described “a ring enhancing lesion” and thought it was probably a tumour. However, he felt he could not rule out an abscess and suggested an MR scan. There was no MR scanner at the local hospital and the MR scan took some time to organise.

Mrs A was admitted to a medical ward and treated symptomatically with analgesia and anti-emetics. Her condition deteriorated over the next 24 hours and the MR scan was brought forward. Dr B, who reported the MR scan, did not know the patient and did not have her notes or previous x-rays. The clinical information on the request form was “glioma – ? for biopsy”. Dr B reported a “space-occupying mass consistent with a neoplasm”’.

Given the findings, Mrs A was referred to the regional neurosurgical centre. It took several days for a bed to become available and for her to be transferred. Her scans were then shown to a neuroradiologist who felt she probably did have an abscess. This was confirmed at surgery which was performed later that day. Mrs A was subsequently transferred to ITU but her condition continued to deteriorate and she suffered a cardio-respiratory arrest and could not be resuscitated.

Mrs A’s husband was critical of the care his wife had received prior to her transfer to the neurosurgical centre. In particular, he felt that had the diagnosis of an abscess been made earlier, his wife would have had a better chance of surviving the surgery. Claims for damages were made against the two radiologists.

Expert opinion

The CT and MR scans were reviewed by an independent neuroradiologist. He acknowledged that neither radiologist had specialist neuroradiological training and differentiating a brain tumour from an abscess on CT or MR can be difficult. However, he felt that if Dr B had seen the original CT, the evolution of the changes should have alerted him to the possibility of an abscess. He also felt that the clinical information provided was inadequate and may have been misleading.

However, MPS continued to defend the case against Dr B, which was dropped shortly after, although it continued against other doctors involved.

Learning points

  • Avoid labelling patient with a diagnosis unless this is proven.
  • Accurate and relevant clinical information should be given when requesting investigations.
  • Previous, relevant imaging should be available at the time of reporting. If you are provided with insufficient information, then you should ask for more, or couch your report in this light.
  • Prioritising reports. Doctors are now pulled in many directions in terms of prioritising their workload. It is important that the overriding consideration is that of clinical need.
  • If there is a differential diagnosis then include it on the report – if you are not sure, then say so and get specialist advice.
  • Working beyond your expertise – if you are asked for an opinion that is beyond your area of expertise then you should decline to give it, and refer the question on to colleagues who are qualified in that area.
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