CSI MEDBLOGS: ATTACK OF THE PUNDITS...CODEBLUEBLOGMD DEFENDS HIS THEORIES

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
• nausea
• vomiting
• fever
• 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.

Opera Bouffe

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!

See:  Medpundit

        RangelMD

Comments

[JR]

You are not being too hard on Zimpfer. The actual medical director of the Rudolfinerhaus was until last Thursday Dr. Lothar Wicke - NOT Zimpfer. Wicke resigned on the day before Yushchenko was set to arrive for his *third* visit to the clinic in order to have his dioxin poisoning diagnosis finally confirmed. Third time is the charm. Wicke persistently rejected this diagnosis as unfounded. For more on "The Strange Case of Dr. Wicke", see here:

http://trans-int.blogspot.com/2004/12/strange-case-of-dr-wicke-or-questions.html

[Lloyd]

Very interesting. Unanswered here is whether Yuschenko is a heavy, moderate, or light drinker? And whether he was engaging in heavy or binge drinking at the time in question? Seems unlikely. This part, at least, should be easy to answer. Also, the guy walking in off the street presumably does not have a big fat target on his back to tempt the world's premier experts in poisons and their use. And how common is alcohol pancreatitis anyways? More common than dioxin poisoning, clearly. But more likely in the midst of an election campaign where Putin, Russia and the KGB are desperately deploying every available resource to fix? Granted, your points about presence of dioxin in liver needs answering. But why is presence of ulcers in the GI tract so easily dismissed?

[dr. charles]

well-researched and presented... i'll agree with rosacea gone wild. it's true about "common things..." my first reaction was something diagnostically sexy like lepromatous leprosy, even though I have never seen a case and it doesn't fit clinically. we need to worry more about getting on base than hitting the home run.

[Pythagoras C]

CBB concedes (see above) that "ulcerations throughout the GI tract" do not fit the diagnosis of alcohol-induced pancreatitis & rosacea. For 2 reasons I believe that this concession is unwarranted and his hypothesis is stronger than he believes:

VY's "GASTROINTESTINAL" ULCERS ARE IN REALITY ONLY GASTRIC.
This is stated in the Oct. 1st Rudolfinerhaus medical certificate: http://www.razom.org.ua/en/news/2357/
The reports of "ulcerations throughout the GI tract" are probably inaccurate.

PANCREATITIS IS FREQUENTLY ASSOCIATED WITH GASTRIC ULCERS.
The correlation has apparently not drawn much attention in clinical practice, but has been confirmed in at least 2 separate recent studies. Importantly for the VY case, one of the studies is from Russia:
"The combination of ulcer disease and pancreatitis in surgical practice" [Article in Russian]
(Medline: http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=14610784 )

See also:
"Gastrointestinal mucosal lesions in patients with acute pancreatitis"
(Medline: http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=12201568 ).
Note that in this study the pancreatitis-associated ulcers were not only gastric but also esophageal and duodenal.

[TallDave]

I will accept my $20,000 in small, unmarked bills. Thanks.

[Chloe]

I'm a little unclear here...
Is the way he looks consistent with alcoholic pancreatitis? Or are you saying that the way he looks might be an "uncommon presentation" of alcoholic pancreatitis? And by "uncommon", does that mean "before unheard of" or "very rare" or "not usually the case"?

Just an FYI - I'm totally understanding that common illnesses can have uncommon symptoms, of course. Myself I had a bad gallbladder (very common), with no gallstones, that made it impossible for me to sit upright in a chair comfortably, and eventually caused the pain to be particularly bad - no chairs for me for many months! This was one of the most debilitating aspects when I was ill, for me, so I was quite vocal about it right from the get-go, even moreso than the other symptoms. No doctors I saw ever heard of such a thing, such a symptom of gallbladder disease... but when I got on-line in some gastro forums, I found that there are others who had that same experience.

My point is this... surely with the doctors this guy is seeing have more access to "uncommon" (but not unheard of) symptoms of various things, than my small town general physicians or even gastroenterologists. Have there ever been cases when someone with alcoholic pancreatitis looking like this?

Of course I'm not saying it's impossible just because it's never happened before - but it would go a long way for me seeing your point if there was some indication he wouldn't be completely unique.

(By the way, thanks for this, because I really didn't realize that there was any question about it. And I don't subscribe to the notion that anyone who questions the poisoning must be politically motivated by the guy's opponent.)

[TallDave]

http://story.news.yahoo.com/news?tmpl=story&cid=514&e=5&u=/ap/20041215/ap_on_re_eu/yushchenko_s_poison

Tests Reveal Yushchenko's Dioxin Level

Remember: small, unmarked bills.

:)

[Jeremy]

CCB I think you've done a good job of putting out your reasoning. You initial alcoholic pancreatitis seems to fit. Of course, we now apparently have the dioxin levels as public record...so we know it's dioxin, but there would be no reason to initially assume that.

Compare:

"Yushchcenko was in satisfactory condition and his dioxin levels have returned to normal, Dr. Michael Zimpfer, director of Vienna's private Rudolfinerhaus clinic, said at a news conference." Dec 11, 2004

with

"New tests reveal Ukrainian presidential candidate Viktor Yushchenko's blood contains the second-highest level of dioxin poisoning ever recorded in a human — more than 6,000 times the normal concentration, according to the expert analyzing the samples." December 15, 2004.

Curiouser and curiouser.

[Pastor M]

PCBs? Maybe hes been eating too much Milk and lettuce imported from the US...

http://www.wired.com/news/technology/0,1282,65884,00.html?tw=wn_tophead_4

But seriously this seems like bullshit. Not to good to admit you drink too much during an election; Better to turn it into an advantage by demonizing the opposition. Rove would be proud (assuming it wasn't his idea.)

[dan]

Should anyone looking for information accidentaly link their way towards this page, i am compelled to add that yushchenko is known for not drinking any alcohol---hence yanukovich's xenophobic suggestion that the disfigurement was the result of bad sushi. i should also add that a person who suspects they may have been poisoned by agents within their country's government would probably not be inclined to visit a hospital in that country. also, having been in a ukrainian hospital myself i would not hesitate to go to a western one if i were having serious health concerns. your president clinton analogy was rather far-fetched for this reason and suggests a general lack of information on ukraine. its seems like you have choosen to pick up on a recently emerging piece of news and learned the facts only to have the chance to debunk them.

[Medical Billing Services]

I'm going to the Ukraine in June. I can't wait to see the changes the new gov't has made.

[Susan R]

This area need serious attention.

[viagra]

Many people fail to open up their inner turmoil even to their spouses. This sometimes land man in very grave situations, especially when it comes to his sexual health. Even though there is a big hype over viagra, you don’t find many people buy viagra from the counters. If you are not keen to discuss their ED problems with a live physician, you can always buy viagra online. After a session of consultation over the net, or after going through your medical history, our online pharmacy can help you to sizzle up your sex life. We are already catering to a big number of patients who order viagra online from us. We have cheap viagra that won’t make a hole in your pocket.

[viagra]

http://www.viagrafire.com works on all cases of erectile dysfunction, whether caused by any physical reason, psychological or due to the old age. You can take Viagra prior to 1 hour of your sexual activity and can see the difference. Viagra starts working inside your body as fast as within 15-30 minutes and stays in your system for complete 4 hrs, giving you enough time to plan your action. Thus http://www.viagrafire.com ViagraFor an instant access to this anti-impotency medicine you can buy http://www.viagrafire.com buy Viagra online You will getcheap http://www.viagrafire.com cheap Viagra at our drugstore which will not only restore the virility of your youth but would also put no pressure on your wallet.

[cialis]

cialis

[Andrew Spark]

I enjoyed your site, but did not see much in the way of advice on invasives.

[Viagra]

nice

[Buy viagra online]

nice thanks viagra pharmacy

[Buy Viagra]

Cool site !

[viagra]

Magical Viagra
http://www.viagrafire.com viagra is well known medicine used to treat ED,Viagra is registered trademark of pfizer. you can http://www.viagrafire.com buy viagra online http://www.viagrafire.com Cheap Viagra is available on internet via trusted online pharmacy. http://www.viagrafire.com Buy Viagra from trusted pharmacy only.

[xanax]

Xanax is a very popular anti-anxiety, antidepressant medicine to help who are suffering from phobias, panic attacks, mild to severe depression and insomnia. If you are wondering about taking http://www.buy-xanax-online-now.com xanax or not, you can log onto our website and know all the information about Xanax. Again, it is advisable that you should not take Xanax without doctor’s advice. So please go through all the Xanax articles and facts on Xanax and then decide if you would like to take Xanax or not. Xanax is the best antidepressant. What is more, we offer best deal for Xanax. You can buy cheap Xanax online from us and that is genuine. So do not wait suffering from depression, panic and insomnia. http://www.buy-xanax-online-now.com buy xanax online and get rid of depression. This is what we offer you, peace of mind, so that you can http://www.buy-xanax-online-now.com buy xanax after reading all the information and then get http://www.buy-xanax-online-now.com cheap xanax online. So, sleep peacefully and get your smile back with Xanax. Do not wait any more, buy http://www.buy-xanax-online-now.com xanax online.

[viagra]

Is your sexual life at stake? Are you suffering from ED? Is your wife avoiding you and you feel so helpless and unhappy? http://www.viagracare.com buy viagra online, and get back to your normal sexual life. This is a time when you should decide if you are going to cry over the situation rest of your life or you are going to change things and order http://www.viagracare.com viagra. There are ways you can http://www.viagracare.com buy viagra and keep it secret. You wish to know about the scientific reasons of erectile dysfunction and then you want to decide if you should use Viagra or not, I tell you, there is a website which gives you all the information. Right from Viagra prescription, dosage, to side-effects, you can know everything about Viagra and buy Viagra. So do not wait and log on to the Viagra site and order http://www.viagracare.com cheap viagra! You are amazed, aren’t you? Yes, there is genuine website which offers cheap Viagra. You need to order http://www.viagracare.com viagra online and they will send it to your door step. So do not worry and go online, relax and read about Viagra and ED. Then buy cheap Viagra online and enjoy your sexual life again.

[Yahoo!]

Browse The Links:
http://www.yahoo.com
http://www.generic-viagra-247.com
http://www.google.com
http://www.budget-levitra.com
http://www.budget-meridia.com

[cialis]

When the erectile dysfunction problem hits hard running straight towards the nearby
doctor becomes the norm. The physician advises to try your hand at drugs that effectively
works against impotency but which one to choose from amongst the numerous species available in the market. In utter confusion some people generally forget to http://www.buy-cialis-online-now.com buy cialis and remain a step behind their peers. It is up to you to care for yourself by going for http://www.buy-cialis-online-now.com cialis online. http://www.buy-cialis-online-now.com buy cialis online as soon as you can for it stays as long as 36 hours or two days in the system thereby giving a boost to your sexual freedom. http://www.buy-cialis-online-now.com cialis is known as http://www.buy-cialis-online-now.com cheap cialis for its affordability and relatively cheaper, negligible price.