Deceased
Jan Axel Pettersson
Demographics
71y, male
Date of death
2017-11-10
Finding date
2020-04-07
Cause of death
disseminated fungal (Cryptococcus) infection of the lungs, brain and meninges
AI-generated summary
A 71-year-old man presented with fever, confusion, and gait disturbance in October 2017. A lung mass was identified on chest X-ray and presumed malignant, but inflammatory markers were unremarkable. Despite clinical deterioration with headaches, altered consciousness, and neurological symptoms suggesting intracranial involvement, diagnostic workup was incomplete. MRI and lumbar puncture were not performed early enough to investigate CNS involvement. The patient was discharged then readmitted, deteriorated further with cardiac arrest, and died. Autopsy revealed disseminated cryptococcal infection of lungs, brain and meninges—not lung cancer. The coroner found management poor, with missed diagnostic opportunities and inadequate investigation of neurological signs. Early lumbar puncture and appropriate antifungal therapy could have prevented death.
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Specialties
Error types
Clinical conditions
Procedures
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