Patient Claims Neurotoxin Injections Caused Meningitis

Background Facts

C presented to an oral and maxillofacial surgeon, Dr. I, upon the referral of a close friend of hers whom Dr. I had previously treated. C’s sole complaints related to facial wrinkles adjacent to the commissures of the lip and the nasolabial folds. She was 67 years old and reported a medical history that included current well-controlled hypertension, well-controlled atrial fibrillation (for which was treated with a beta-blocker and a direct anticoagulant), anxiety and depression, and 2 episodes of viral meningitis some 30 years prior. Her surgical history was limited to tonsillectomy, repair of a few fractured bones as a child, and a C-section.

Dr. I evaluated his new patient and advised her that he believed her to be an excellent candidate for an injectable neurotoxin – a drug made from a toxin of Clostridium botulinum, which has gained great popularity over recent times. Dr. I explained the risks of bleeding, infection, failure to eliminate the wrinkles fully, the need to redo the procedure as soon as a few months later, and temporary bruising (especially because she was taking an anticoagulant). C had deeply researched what she was getting into, so she had been aware of these risks all along, and in fact interrupted Dr. I during his explanation with a number of “I know” and “there’s no need to even explain this to me” comments. She agreed to go forward, signing the “consent form” provided to her.

The procedure went forward uneventfully. As 1 week post-op approached, C developed a fever, a severe headache, and a stiff neck. She called Dr. I, who saw no relationship to the recent procedure, and suggested that it might be influenza. These symptoms reminded her of the prior meningitis events, so when she felt even worse the next day, she presented to a hospital emergency department. Especially considering the patient’s history, even though many years prior, a complete neurological work-up was performed to include blood work and CT scans, the attending neurologist became concerned. So he ordered a lumbar puncture to assess the cerebrospinal fluid. CSF findings were consistent with viral meningitis, although not definitive, so C was admitted for supportive care, antiviral medications, and a watchful eye.

From the time she came into the hospital until her discharge 5 days later, C was extremely anxious, requiring anti-anxiety medications. Although feeling constitutionally better, she remained far more anxious beyond her baseline, so she began care with a mental health provider, and continued for several months. C concluded that her cosmetic treatments were not worth what she had gone through, both subjectively and financially, and vowed to never do that again.

Legal Action

C approached a local law firm to discuss the potential of suing Dr. I for malpractice. C did much research to look at potential bases for a lawsuit. She explained to the attorney that she believed that Dr. I had erred in failing to provide her with the risk of “the neurotoxin crossing the blood-brain barrier (BBB),” so as to cause the meningitis event. She contended that she had a “weak” BBB, which made her more susceptible to the neurotoxin crossing that barrier and invading her central nervous system, and that Dr. I should have recognized that based upon her disclosed history, and therefore refused to perform the procedure. C wanted compensation for her hospitalization and her increased anxiety.

The attorney sent a letter to Dr. I, requesting C’s records and stating that he intended to file a claim on behalf of C. Dr. I passed this information on to his malpractice carrier, which, upon his request, assigned defense counsel to represent him, given that a claim had been threatened.  Counsel provided a copy of the records to C’s attorney and also had an attorney-to-attorney discussion by telephone. C’s attorney fully explained his planned litigation approach, namely one founded on lack of informed consent because Dr. I never explained to C the risk potential for the neurotoxin to cross the BBB and cause meningitis.  

Both Dr. I and his counsel were skeptical of the theory, so a neurologist was contacted to provide thoughts about the concept suggested. That neurologist responded in a report, after a review of the records, that the arguments in support of a potential case were not valid: (1) there was no medical record which, in any way, indicated a weak or compromised BBB. And (2) even if that were the condition and the neurotoxin made its way into the central nervous system – which the neurologist believed to be extremely unlikely – meningitis is an infection, and C had been warned about the potential for infection, which she acknowledged in writing. In short, the neurologist’s opinion was that the current meningitis was entirely unrelated to, and coincidental with, the facial injections. The report was shared with C’s attorney, with the hope of staving off a lawsuit.

C’s attorney discussed the contents of the report he had just received with his client. C’s response was that the only potential infection that Dr. I had discussed with her was local to the injection site, but nothing systemic. C was shown the document she signed, which was no more specific than listing “infection” as one of the risks. With the lack of medical evidence to support C’s theory of her weak BBB, C’s lawyer refused to move forward with any suit against Dr. I. No further action was taken by C against Dr. I.

Takeaways

While Dr. I was never sued by C, that does not mean that there are not meaningful risk management concepts to learn through this case study. Perhaps the most significant of those lies with patient selection. Experience demonstrates that certain types of patients tend to be more litigious than others. That is not to say that all such patients will sue, or that all suits are started only by patients in those groups, but it is to say that a more wary eye should be directed when a patient shows him/herself to exhibit behaviors sometimes seen in more litigious people.  

This patient might well be referred to as a “patient as doctor” patient. In other words, she convinced herself that, by virtue of her own extensive research, she knew all that there was to know, and perhaps even more than the doctor, about what was ahead of her from a treatment perspective. Therefore, she presented to Dr. I, believing that she knew all of the information that was available, and she made that clear with her multiple and very telling interruptions while he discussed procedure risks, perhaps paying little or no attention to what was being explained to her. That might well explain her later stated belief that it was only local, and not systemic, infection that she had been advised about. Interestingly, she demonstrated quite similar behaviors when speaking with her attorney.

The point made here is not to suggest that oral surgeons should not treat any patient whose personality they do not relate to – although that option does exist, especially for non-emergent situations – but to suggest that patient assessment leading to patient selection is an important protective risk management tool.

Oral surgeons are obligated to obtain their patients’ informed consent prior to invasive procedures, which properly includes advising of foreseeable risks. Forms used in conjunction with that process should be worded to correlate with the information provided.

Finally, this case exemplifies the benefits of both Dr. I timely advising his malpractice carrier of his patient’s threatened action, and the carrier’s early intervention in engaging defense counsel (because Dr. I’s policy provisions allowed for that), who immediately retained a knowledgeable expert to educate defense counsel with the medical means to stop a potential event from becoming an actual one. When doctor, malpractice carrier, defense counsel, and expert all work in concert, a chance for a successful outcome is possible.

Note that this case presentation includes circumstances from several different closed cases, in order to demonstrate certain legal and risk management principles, and that identifying facts and personal characteristics were modified to protect identities. The content within is not the original work of MedPro Group but has been published with consent of the author. Nothing contained in this article should be construed as legal, medical, or dental advice. Because the facts applicable to your situation may vary, or the laws applicable in your jurisdiction may differ, please contact your personal or business attorney or other professional advisors if you have any questions related to your legal or medical obligations or rights, state or federal laws, contract interpretation, or other legal questions.