Case 15 Ill-fitting dentures in an elderly man

Alfred was a 74-year-old man with previously good health who rarely attended the surgery. He consulted Dr McDowd with a two-week history of ‘flulike’ symptoms, fever, sinusitis and lack of appetite. He had lost a little weight but he attributed that to problems he was having with his dentures. Dr McDowd found that Alfred was apyrexial with a clear chest and prescribed amoxicillin.

Eight days later Alfred consulted Dr McDowd again. He felt a little better but his wife was concerned that he had lost some more weight. He was seeing his dentist because his lower denture was causing him pain, which inhibited him from eating. His fever had gone but he still had sinus pain. Dr McDowd found a temperature of 37.4 C and a normal pulse and blood pressure. He prescribed doxycycline.

What would you do now?

Three days later Alfred’s wife telephoned Dr McDowd and explained that she was worried about her husband. He was not eating, was not himself and the problems with his dentures were ‘getting him down’. She wondered if he had an infection in his sinuses. Dr McDowd arranged some blood tests and sinus X-rays.

The following day Alfred saw Dr Elsworth at the practice. He explained that he had picked up an infection a few weeks ago and had been ‘unable to shift it’. He was wondering about another antibiotic. Dr Elsworth noted that Alfred had malaise, weight loss, generalized aches and pains and sinusitis. He noted that Alfred had not had the blood tests or sinus X-rays. He rang the radiology department and was informed that they no longer did sinus X-rays at the request of general practitioners. He prescribed some clarithromycin and a nasal decongestant.

The following day Dr McDowd received the blood test results. Alfred had a CRP of 70 mg/l and an ESR of 64 mm/hr. His full blood count showed an anaemia of 10.9 g/dl with a normal MCV. Dr McDowd also received a form from an optician stating that Mr McDowd had had intermittent double vision but that examination was normal. Dr McDowd requested a serum ferritin, B12 and folate and a fasting blood glucose.

What would be your differential diagnosis and how would you discriminate between them?

The following day Alfred rang Dr McDowd and told him that he could had woken unable to see out of his left eye. Dr McDowd advised him to go straight to A&E. The A&E SHO elicited a history of jaw claudication and bi temporal headache and impalpable temporal arteries. A diagnosis of giant cell arteritis was made. Alfred was admitted and started on high dose methyl prednisolone but did not regain the sight in his left eye.

A claim was brought against Dr McDowd and Dr Elsworth that they should have suspected that Alfred could have giant cell arteritis, started him on high dose corticosteroids and referred him.

Do you think his claim will succeed?

Expert comment

Headaches and facial pain are extremely common presentations in general practice and patients often self diagnose acute sinusitis incorrectly (Murtagh, 2004). Most patients with acute sinusitis will have objective fever and a purulent nasal discharge as well as facial pain or headache (Williams & Simel, 1993). Acute sinusitis is comparatively unlikely unless all three are present.

General practitioners need to be extremely cautious with the assessment of headaches in the older patient. The commonest causes of headaches, tension headaches and migraine, are not common in the elderly. Giant cell arteritis is not particularly rare in this age group and a full-time general practitioner will see a new case every couple of years. The presentation is often atypical with typical temporal headache being absent in nearly 50% of patients. Patients with ischaemic symptoms (jaw claudication and/or visual disturbances, including diplopia) are at high risk of sudden visual loss (Slavarni et al., 2005). Yet these patients (and the patients with predominantly systemic symptoms of weight loss, fever, myalgia and malaise) are the most likely to be missed by doctors (Ezeonyeji et al., 2011).

In this case both Dr McDowd and Dr Elsworth did not pick up on several clues: malaise and weight loss in a 74 year old is usually not due to mild self-limiting disease. Facial pain due to acute sinusitis is uncommon in this age group. Alfred effectively had high inflammatory markers that were not otherwise explained. A new history of multiple consultations together with expressions of concern from a spouse is often an indicator of serious disease in an elderly person. However, the main problem appears to have been that the general practitioners were not sufficiently aware of the protean manifestations of GCA and the requirement of a very high index of suspicion to avoid missing the diagnosis. A 2002 systemic review analyzed 1435 cases of GCA. The mean duration of symptoms by the time of diagnosis was 3.5 months. Case Table 2.1 indicates the protean manifestations of the condition (Smetana & Shmerling, 2002),

Table 2.1 Protean manifestations of GCA.

Legal comment

Neither Dr McDowd nor Dr Elsworthy recognized that they were dealing with a number of high inflammatory markers which needed an explanation. If high dose cortico-steriods had been prescribed sooner and an urgent referral had been made would the sight in Alfred’s left eye have been saved?

A GP expert will have to analyze the case in retrospect to identify the point at which Alfred should have been recognized as an emergency. Then an ophthalmologist will have to assess whether an urgent referral at that point would probably have saved the sight in Alfred’s left eye. If the answer is yes, probably, then compensation will have to be paid to Alfred. The compensation for his pain and suffering is likely to be in the region of £35 000. Alfred may be able to claim further damages, if he will require extra care as a result of his lost vision in the left eye.

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