According to a story from the Hereford Times, a combination of misdiagnosis and a critical mistake to forgo a simple blood test led to the tragic death of Callum Cartlidge. Callum was dead only a day after being discharged from the Worchestershire Royal Hospital. Doctors diagnosed him with gastroenteritis, but he was in fact experiencing an adrenal crisis because of his Addison’s disease. The cause of death was cardiac arrest, in which a loss of blood flow leads to heart failure.
Addison’s disease, also known as primary adrenal insufficiency, is a long term disorder in which the adrenal glands fail to produce sufficient quantities of steroid hormones. The disease can be caused by an event that affects the function of the adrenal glands. In the developed world, an attack from the body’s own immune system which destroys the adrenal cortex is the most common cause. Tuberculosis is a common cause in the developing world, and very rarely genetic mutations can be responsible. Many symptoms are very nonspecific, so Addison’s disease can get misdiagnosed easily. They tend to develop slowly, and can include general weakness, darkening of the skin, abdominal pain, and weight loss. To learn more about Addison’s disease, click here.
When he was admitted to the hospital, Callum was having an Addisonian adrenal crisis. Such an episode indicates severe adrenal insufficiency, and can be a patient’s first encounter with their disease. Symptoms include fever, convulsions, sudden pain in the legs, lower back, or abdomen, elevated calcium and potassium levels, lowered sodium levels and blood glucose, fatigue, diarrhea and vomiting, loss of consciousness, and low blood pressure. Addisonian crisis is a medical emergency that requires prompt treatment. His crisis was triggered by a viral infection.
Callum was sent home with rehydration salts. Another mistake included a poorly recorded fluid chart which led to confusion over how much fluid he had received. A leading expert on Addison’s said that he had never seen the disease present the way it had in Callum. Regardless, a blood test would have recognized the telltale changes in the concentrations of various substances in his blood.
The NHS trust that evaluated the case issued its sincerest apologies, but Adie and Stacey, Callum’s parents, believe that their own concerns regarding his condition were downplayed. This tragedy highlights the fact that many rare disease patients are often at great risk because many trusted medical professionals are unaware of the signs and symptoms of their condition. In Callum’s case, lack of awareness combined with poor care led to his untimely passing, and should have been prevented.