Case Presentation: A 44-year-old man with multiple myeloma and cardiac amyloidosis on chemotherapy, and atrial fibrillation on apixaban, presented with three days of worsening shortness of breath and edema. He was admitted to the emergency room observation unit for treatment of a mild heart failure exacerbation. He was noted on admission to have rapidly developed new erythema and tenderness in his left groin region, and vancomycin was started for treatment of cellulitis. In the early morning, he was transferred to the inpatient hematology service due to the cellulitis and heart failure, at which time cefepime was added. When he was assessed by the day team in the morning, the rash was noted to be rapidly spreading down his left leg with increasing tenderness, associated tachycardia and hypotension. Computed tomography of the leg was ordered to evaluate for abscess. Infectious Disease was consulted, who noted extensive erythema extending from left flank to left calf with indistinct margins, possible crepitus, and severe pain, which were highly concerning for necrotizing soft tissue infection. Surgery was consulted and antibiotics were broadened to include meropenem and clindamycin. He was then taken emergently to the operating room, 18 hours after initial presentation, for surgical exploration. He had a PEA arrest shortly after induction of anesthesia resulting in death, despite 20 minutes of cardiopulmonary resuscitation. Autopsy showed acute inflammation with focal necrosis involving skin and subcutaneous tissue of left lower extremity and flank, consistent with necrotizing soft tissue infection.

Discussion: This case was identified as part of a multi-center study evaluating diagnostic error as a contributor to in-hospital death or ICU transfer. Reviewers of this case though a diagnostic error was HIGHLY LIKELY. The error was thought most related to a number of diagnostic process faults, including failure or delay in considering the diagnosis of necrotizing soft tissue infection as a result of suboptimal weighing of a physical exam demonstrating rapidly progressive rash and pain, in an immunocompromised patient. While Infectious Disease was consulted, delay in considering this diagnosis resulted in delay in surgical consultation. Meanwhile, multiple hand-offs occurred from presentation to the PEA arrest, including providers of the emergency room, the observation unit, the night shift and the day team, which likely contributed to slow consideration of diagnosis. In addition, the patient’s presenting symptoms were cardiopulmonary, and the rash was only noted during a subsequent assessment, which may have created some anchoring by shifting the focus more on heart failure management and away from evaluation of the infection. Overall, the error resulted in a delay in surgical management, which likely contributed to the rapid decompensation and death of the patient, although the outcome may not have changed given the morbid nature of the disease and the patient’s underlying comorbidities.

Conclusions: Early consideration of diagnostic imperatives such as necrotizing soft tissue infection should remain an education focus in decreasing diagnostic errors. Reconsideration of differential diagnosis during care transitions is often necessary, particularly if new findings are present, to prevent missing imperative diagnoses.