Attack of the Pundits
With a reference by Instapundit yesterday, my post about this past weekend's events at Rudolfinerhaus in Vienna got widespread attention -- and that's okay -- however, many visitors read that one post (or read that and skimmed others) and came away with the wrong message as to my explanation of this case.
I've been posting about Yushchenko's mysterious disease since 11/30/04, before there was much talk about anything except "poisoning."
Since I've taken a few shots by people picking out points and sub-points (and I've even been accused of amassing circumstantial evidence towards conspiratorial theories!) in my discussion, let me summarize my position as I posted it, from the beginning.
Treat This Patient
If you are a physician, in the Emergency Department, and a man comes in saying he has bad abdominal and back pain, how do you approach this as a physician? You take a history, examine him, do the lab work, and then draw up a list of possibilities (in medicine we call this list the differential diagnosis) in order of likelihood from most likely to least.
That's how I approached this case on 11/30/04. Here were the data available:
- 50ish male out for a long dinner develops severe abdominal pain next day
- Four days later the pain forces him to the clinic and now he also has back pain
- Labs show elevated white blood cell count
- CT shows "swelling and inflammation" of the pancreas and liver (as a radiologist, to me this means enlarged liver and pancreatitis)
- He has a malar (cheeks and nose) eruption (see my original post, the eruption was less severe, earlier in his course)
Now, this 50ish male is a well-known figure and HIS proposal to me, as the ED MD, is that he was poisoned. The brief history is all you get -- that's all I got.
Doctors? What is your differential diagnosis starting with the most likely diagnosis first? Answer in unison, please. Alcoholic pancreatitis. No doctor worth his or her examining glove would say anything else as the first choice. You'd put down an NG tube (naso-gastric tube through the nose into the stomach) and admit him. There can be no argument about this.
65-75% of pancreatitis cases are caused by alcohol or gallstones. There is no mention of gallstones in the history or work up. Pancreatitis can be brought on by chronic over-consumption of alcohol or by binge drinking. For the nonmedical people, here is one description of the presentation of acute pancreatitis:
Acute pancreatitis usually begins with pain in the upper abdomen that may last for a few days. The pain may be severe and may become constant--just in the abdomen--or it may reach to the back and other areas. It may be sudden and intense or begin as a mild pain that gets worse when food is eaten. Someone with acute pancreatitis often looks and feels very sick. Other symptoms may include
- swollen and tender abdomen
- rapid pulse
Severe cases may cause dehydration and low blood pressure. The heart, lungs, or kidneys may fail. If bleeding occurs in the pancreas, shock and sometimes even death follow.
What I have said, since the beginning is that: Yes, Viktor Yushchenko may have been poisoned, and I would not hesitate to investigate that hypothesis, test it, and believe it; however, until I have documentation, or quantifiable information that I trust, and that indicates otherwise, I am diagnosing and treating this patient for pancreatitis, and my assumption is alcoholic pancreatitis. In MY mind, to treat this patient any other way, given this scenario, would be wrong.
There have been very few revelations in this case that move me off that diagnosis except the report of ulcerations throughout the GI tract, which I stated, without hesitation, does not typically fit my diagnosis.
What About That Face?
As for rosacea, I disagree with all those who have said that it does not look like what Yushchenko has and that rosacea does not progress this rapidly. Rosacea can be explosive, and extremely disfiguring -- and it can be triggered by even one alcoholic drink. In five years of work at major inner city hospitals in Manhattan, I saw several such cases. Again, if you look at Yushchenko's face early on (see here), his disfigurement was much less severe. He had a spidery, red, malar eruption.
I agreed that Yushchenko's face has since transmogrified into something quite unusual and my first suggestion is that he was coating the eruption with pancake make-up; however, for anyone to adduce his facies as proof of poisoning, I would accuse that person of a logical error in trying to make a diagnosis from a clinical SIGN, which can be a common endpoint of many different pathophysiologic pathways.
As I have mentioned several times to commentators on my site, an important maxim for medical students is this:
You are much more likely to encounter an uncommon presentation of a common illness than a common presentation of an uncommon illness.
Chloracne or Rosacea? It's a straight-forward choice for me.
Which leads to the farce this past weekend. I have been rebuffed for being hard on Dr. Zimpfer at the Rudolfinerhaus clinic this past weekend. However, I was expecting him to tell us what test they did and the results. And what did he say? It's poison. Case closed.
I gladly would have written a post describing the mystery, now revealed, as Dioxin poisoning (and a case for the annals, indeed); however, Zimpfer really just kicked us all out of his private clinic with no more quantifiable knowledge than we had when Yushchenko arrived.
And why did Viktor even go to Rudolfinerhaus this weekend? To have his blood drawn? They certainly had no time between Friday night and Saturday morning (when they said they had results to be announced at 1400) to do skin or visceral biopsies and analyze them appropriately. As it is, in that short time, they sent Yushchenko's blood to Amsterdam for some new test that diagnosed Dioxin poisoning (although they implied that his blood levels are normal).
These obvious subterfuges, coupled with Katerina giving press conferences about tasting the poison on Viktor's lips... and the children's choir singing in the background as Yushenko says he doesn't want any of this investigated right now -- I don't know, it just seemed like there was a need for parody.
So, I'm sticking with what makes sense to me, until I have some believable proof that the most likely diagnoses are knocked off their pedestals by the freakish and improbable. But I can accept that if it happens. Capita!