Clinical knowledge gaps and oversights endanger patients and practitioners

Sore throat and fever are common presentations in general practice. While usually caused by viral infection and self-limiting, persistent or worsening symptoms, especially in patients with comorbidities, require investigation for sinister causes.

The following two cases involve patients presenting with nonspecific upper respiratory tract infection symptoms who were later diagnosed with drug-induced agranulocytosis caused by an anti-thyroid medication (Carbimazole). In both instances, the Medical Council of Hong Kong (MCHK) conducted disciplinary inquiries and issued removal orders against the attending doctors. 

Case one: Failure to warn and monitor 

Patient A consulted Dr. H for a thyroid condition and was prescribed Carbimazole. During follow-ups, the patient developed eye redness, epistaxis, urticaria, shortness of breath, and tachycardia. Despite these warning signs, Dr. H increased the Carbimazole dosage. When the patient returned with a sore throat and gum infection, Dr. H prescribed antibiotics. Patient A was subsequently hospitalised with sepsis secondary to drug-induced agranulocytosis and hyperthyroidism, requiring prolonged recovery. The MCHK found Dr. H failed to inform the patient of Carbimazole’s potential side effects prior to prescription. 

Case two: Inadequate history and inappropriate treatment 

Patient B presented to Dr. L with fever and sore throat and informed Dr. L that she was taking thyroid medication. Dr. L diagnosed acute tonsillitis and prescribed antibiotics without inquiring further about the thyroid regimen. When symptoms persisted and mouth sores developed, Dr. L prescribed medications including Prednisolone (a steroid). The patient later coughed up blood-stained sputum, was admitted to the intensive care unit with respiratory failure and ultimately succumbed to multiple organ failure. During the inquiry, Dr. L admitted that he was unaware Carbimazole could cause agranulocytosis. The panel also heavily criticised the inappropriate prescription of steroids, which exacerbated the condition.

Key learning points 

• Take a comprehensive drug history 
  Always ascertain the name and nature of current medications. Presenting symptoms may stem from drug interactions or side effects. 
• Maintain current knowledge 
  Stay abreast of medical literature and developments, including rare but serious side effects of common medications. 
• Inform patients 
  Warn patients about common and specific side effects before prescribing. Importantly, rare side effects warrant disclosure when they are significant from the patient’s perspective. Explain clinical manifestations of serious reactions (e.g. mouth ulcers may indicate agranulocytosis in patients taking anti-thyroid medications). 
• Prescribe steroids with caution 
  Ensure appropriate indications exist before prescribing steroids, particularly in complex cases. 
• Re-evaluate stagnant cases 
  If a patient does not recover as anticipated, review the diagnosis and consider alternatives. Refer promptly to emergency or specialist care when red flags appear.