Case Presentation: A 63-year-old woman with end-stage renal disease on dialysis and bilateral lung transplant was admitted from a rehab facility with generalized weakness and anemia in the setting of missed dialysis. At presentation, she had fluid-responsive hypotension, borderline fever, and a normal heart rate. She had no localizing infectious signs or symptoms. An infectious work up was collected, but she was not started on empiric antibiotics. Her weakness was attributed to the worsened anemia and missed dialysis. Overnight, she developed a fever to 38.3 C. The next morning a procalcitonin resulted critically high, which prompted initiation of empiric antibiotics by the primary team. However, there was a further delay in administering the antibiotics until 10pm that evening. An hour before getting the first dose of antibiotics she spiked another fever to 38.9 C, and several hours later developed worsening hypotension requiring transfer to the ICU for pressors in the setting of atrial fibrillation with rapid ventricular response and septic shock.
Discussion: This case was reviewed as part of a national collaborative (Achieving Diagnostic Excellence through Prevention and Teamwork, ADEPT) aimed at identifying cases of potential diagnostic error. In this case, a diagnostic error was thought to be likely, as there were several opportunities for earlier diagnosis and treatment of sepsis. First, there was a delay in considering the diagnosis. While an infectious work up was started upon presentation, sepsis was not included in the differential at the time of admission. Anchoring on the worsening anemia and missed dialysis as well as the patient’s atypical presentation with no localizing infectious signs are possible contributing factors to this delay. Second, there was suboptimal communication between different members of the care team as there is no indication that the overnight provider was made aware of the patient’s new fever. Third, there was a failure to respond to clinical change (true fever overnight) and abnormal diagnostic test (newly elevated procalcitonin) in a timely manner; antibiotics were not ordered for several hours after these occurred. Additionally, there was a multiple-hour delay between the antibiotics being ordered and administered, reflecting an opportunity for systems improvement. The diagnostic error in this case was considered to have contributed to her need to transfer to the ICU as earlier antibiotic administration may have prevented her clinical progression into shock.
Conclusions: Sepsis is a common diagnosis in the hospital, and with common diagnoses there will sometimes be uncommon and atypical presentations. Early diagnosis of sepsis is essential as a multitude of studies have shown earlier administration of antibiotics leads to decreased mortality (1). This case highlights both system and individual opportunities for improved diagnosis. Systemic changes may be aimed at more timely overnight communication of a clinical change and more efficient administration of ordered antibiotics. It is important to remember that some patient populations, including those who are immunosuppressed due to transplant, may not present with typical findings in early sepsis. When admitting patients to the hospital it is important to maintain a broad differential to avoid anchoring, which could have helped establish a diagnosis of sepsis earlier in this case.