SHM Converge Scientific Abstract ePoster Gallery-Missed in the Shift -- Delay in Making an Imperative Diagnosis Amidst Care Transitions

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This case describes a 44-year-old man with multiple myeloma, cardiac amyloidosis on chemotherapy, and atrial fibrillation who died from delayed recognition of necrotizing soft tissue infection. He initially presented to the ED with worsening shortness of breath and leg edema and was admitted for mild heart failure exacerbation. During ED observation and later on the medicine service, he developed rapidly spreading erythema and tenderness in the left groin/leg, but this was initially treated as cellulitis with antibiotics while attention remained focused on heart failure.<br /><br />Over the next several hand-offs, the rash progressed with escalating pain, tachycardia, and hypotension. The day team broadened the workup, ordered CT for possible abscess, and infectious disease raised strong concern for necrotizing soft tissue infection due to extensive erythema, indistinct margins, possible crepitus, and severe pain. Surgery was consulted, but by then the patient required emergent operative exploration and suffered PEA arrest after anesthesia induction without return of spontaneous circulation. Autopsy confirmed necrotizing soft tissue infection involving the skin and subcutaneous tissue of the left lower extremity and flank.<br /><br />The presentation highlights a diagnostic error likely driven by anchoring on cardiopulmonary symptoms and delayed reassessment of new skin findings during care transitions. Contributing failures included underweighting the significance of rapidly progressive rash and pain in an immunocompromised patient, delayed consideration of necrotizing infection, delayed surgery consultation, and delayed re-examination. The case emphasizes the need to maintain awareness of diagnostic imperatives like necrotizing soft tissue infection and to reconsider the differential diagnosis whenever new findings emerge, especially across hand-offs.

Asset Subtitle

A Shams Helminski

Meta Tag

Author List A Shams Helminski, Angela Alday, James Anstey, Mengyu Zhou

Category Clinical Vignettes

Concept Necrotizing Soft Tissue Infection

Concept Diagnostic Delay

Concept Diagnostic Error

Concept Anchoring Bias

Concept Skin and Soft Tissue Infection

Distinguished Non-Finalist

Presenter Organization Oregon Health and Science University

Presenting Author A Shams Helminski

Track Adult

Keywords

multiple myeloma

cardiac amyloidosis

atrial fibrillation

necrotizing soft tissue infection

cellulitis

diagnostic error

anchoring bias

hand-off communication

immunocompromised patient

emergent surgery

Necrotizing Soft Tissue Infection

Diagnostic Delay

Diagnostic Error

Anchoring Bias

Skin and Soft Tissue Infection