Tuberculosis remains a major cause of death by infection in the world. Disseminated tuberculosis occurs most frequently in the context of reactivation of a previously latent infection and is invariably lethal if untreated. Age, late presentation, and serious underlying disease are strong death predictors. We report the case of a 72-year-old male patient who presented to the emergency room with sudden onset hemiparesis and aphasia, with no acute lesions on contrast CT. Two months prior to the current event, the patient had undergone surgery for a testicular abscess in a different hospital. Since the surgery, he had progressive and unexplained weight loss and dysphagia. The medical team reviewed patient records from this hospital and the one where the surgery took place and concluded that the histopathology results from the surgery were not reviewed in the post-surgery follow-up consult and that the diagnosis of genitourinary tuberculosis was never made. This disease, untreated, evolved into disseminated tuberculosis with central nervous system involvement, causing the neurological deficits the patient presented and leading to his death. Surveillance and notification systems exist for individual and public health safeguarding. In the present case, failure to review the pathology report after surgery, coupled with the absence of notification from the laboratory, delayed the diagnosis and led to patient death. This report suggests a need for continuous system improvement, with integrated healthcare records and interinstitutional communication channels, in order to minimize information loss, diagnostic delays, and public health risks.
Keywords: disseminated tuberculosis; medical error; public health; tuberculosis; tuberculous meningitis.
Copyright © 2023, Fidalgo et al.