Articles and Case Studies

Send to Pathology

31 Jan 2007

Dr Sara Bird

by Dr Sara Bird

On 2 August 2002, the 52 year old patient saw her GP complaining of a ‘wound’ on the sole of her left heel.

Case history

The GP thought the lesion was an infected laceration or wart. She prescribed Keflex. The patient returned on 9 October 2002 stating that the ‘wound was still present on the sole of her left heel’. The GP ordered an ultrasound to exclude a foreign body. At review on 16 October 2002, the GP noted that the wound appeared to be healing. The ultrasound did not reveal any foreign body. The GP referred the patient to a dermatologist for review.

On 29 October 2002, the patient saw a dermatologist, Dr Barker, who reviewed her left heel and noted a ‘small 2mm erosion with dermis intact’. He requested a repeat ultrasound and x-ray of the heel. Both of these investigations were normal. Dr Barker made a provisional diagnosis of a staph or strep infection and commenced the patient on Flucloxacillin. He asked the patient to return for review in one week and noted in his records ‘….defer biopsy for histopathology and culture for the present’. On 7 November 2002, the patient returned for review. Dr Barker recorded that the ‘wound was improving’. He expressed some fluid from the lesion and sent this for culture. He changed the antibiotics to Keflex. A full skin check was performed. Some BCCs on the patient’s upper back, chest and leg were noted and arrangements were made for these lesions to be excised at another appointment. On 14 November 2002, Dr Barker noted that the patient’s foot was slowly improving. The culture revealed Staph aureus and the antibiotic therapy was continued.

Dr Barker was on leave in early December 2002 and the patient saw another dermatologist, Dr Jacob, for review of the heel lesion which had flared up. Dr Jacob noted a four month history of a ‘persistent inflammatory lesion involving the left heel’. On examination, he found a ‘slightly keratotic area with a lot of underlying induration and inflammation’. He made a provisional diagnosis of an inflammatory reaction around a foreign body, with a differential diagnosis of an unusual infection. Dr Jacob referred the patient to a plastic surgeon, Dr Pollard, for ‘incision, drainage and tidying up’. He requested collection of specimens for ‘mycobacterial and deep fungal culture’ and commenced the patient on Flucloxacillin.           

The patient saw the plastic surgeon, Dr Pollard, on 6 December 2002. Dr Pollard noted that there was no history of trauma but the lesion had been causing the patient pain and several bouts of infection. He booked the patient for an exploration and debridement of the left heel lesion.

On 9 December 2002, the patient saw Dr Barker again. Dr Barker referred the patient to an infectious diseases physician for assessment. The patient saw the infectious diseases physician, Dr Thomson, on 11 December 2002. Dr Thomson phoned the plastic surgeon and advised him that he thought the heel lesion was unlikely to be an atypical infection given its response to antibiotics but there may be an underlying foreign body. He recommended surgical drainage followed by 10 days of antibiotic therapy.

On 12 December 2002, Dr Pollard performed an exploration and debridement of the patient’s left heel. At surgery, no collection of pus was found and there was only a small ‘area of granulation tissue’. This was explored to determine whether there was an underlying foreign body but none was identified. Specimens were sent for culture. The patient returned to Dr Pollard for review on 16 December 2002. Dr Pollard noted the wound was clean and healing well. The culture revealed a mixed growth of E Coli and Serratia. Dr Pollard discussed the results with Dr Thomson who suggested a course of Trimethoprim. Dr Pollard reviewed the patient for the last time on 23 December 2002 at which time the wound was healing well.

On 11 February 2003, the patient was seen by another infectious diseases physician, Dr Salmon, with ongoing pain in her heel. Dr Salmon requested blood tests, an x-ray and a bone scan. He made a provisional diagnosis of plantar fasciitis and commenced a NSAID. The patient continued to see the dermatologist, Dr Barker, for review. Dr Barker noted ongoing problems with the heel, including tenderness and swelling. Dr Barker wrote to Dr Salmon requesting further review and noted previous tissue was sent for culture only, with no histopathology’. The patient also attended further consultations with an orthopaedic surgeon and a general surgeon in relation to the problems with her heel.

On 29 October 2003, the patient was seen by another plastic surgeon, Dr McGill. Dr McGill performed an exploration of a ‘chronic ulcer left heel’ on 5 November 2003. A specimen was sent for histopathology. This revealed an acral lentiginous melanoma, Breslow thickness 4.4mm, Clark level V. The patient subsequently underwent wide local resection with flap reconstruction and a sentinel lymph node biopsy.

In August 2005, the patient commenced legal proceedings against the plastic surgeon, Dr Pollard.

Medico-legal issues

Surprisingly, Dr Pollard was the only named defendant in the claim.  The central allegation against the plastic surgeon was that he was negligent in failing to request histopathology on 12 December 2002, resulting in an 11 month delay in diagnosis of melanoma. As a result of the alleged delay in diagnosis, the plaintiff (patient) claimed that she had lost the chance of a better prognosis and had suffered psychological injury and physical damage from the surgery on her heel. The plaintiff served an expert opinion from a plastic surgeon who concluded ‘Dr Pollard’s management of the plaintiff in the context of this referral falls below that widely accepted in Australia by peer professional opinion as competent proficient practice. It is my view that Dr Pollard should have taken a biopsy for histological examination’.

Expert opinion was sought on behalf of Dr Pollard from a melanoma surgeon. The surgeon stated that the plaintiff’s melanoma was of a ‘type which is virtually never diagnosable as melanoma on first presentation’. He stated that had the melanoma been diagnosed on 12 December 2002, her proposed surgery would not have been any different from that performed in November 2003.  However, the surgeon noted that the alleged delay in diagnosis from December 2002 until November 2003 would have affected the plaintiff’s ultimate prognosis, but the extent to which the prognosis had been affected could not be quantified with any certainty. Based on statistical tables, the expert estimated that the plaintiff’s five year survival rate in December 2002 was 63% and at the time of the diagnosis in November 2003 the reported five year survival rate was 45%.

The claim was settled for $100,000 plus plaintiff’s (patient’s) costs in August 2006.

The settlement amount was discounted on the basis that the 11 month delay in diagnosis had not substantially altered the plaintiff’s long term prognosis and had had no impact on the surgical management of the patient. 

The settlement sum was apportioned as follows:

  • 50% - Dr Barker, dermatologist
  • 35% - Dr Pollard, plastic surgeon
  • 15% - Dr Thomson and Dr Salmon, infectious diseases physicians

 

Discussion and risk management strategies

This case highlights:

  • The difficulty in diagnosing acral lentiginous melanoma; and
  • The importance of histopathology

 

Lesions which are suspicious or cannot be diagnosed after a period of observation should be biopsied/excised and the tissue sent for histopathology.

In this case, a number of practitioners failed to undertake a biopsy and histopathology, despite the fact that the heel lesion failed to resolve and no definitive diagnosis had been made.

General Practice, Sports Medicine, Surgery
 

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