CSI MEDBLOGS: AMERSTERDAM SAYS IT'S SO: YUSHCHENKO IS DIOXINIZED

It Was a Zebra After All?

A toxicologist at the Free University in Amsterdam reports tonight that his analysis of Viktor Yushenko's blood reveals:

100,000 units of dioxin per gram of blood fat

And there is widespread talk this may be the highest level ever recorded -- although why that is headline news everywhere is a mystery.

However, toxicologists are baffled -- as was this blog -- as to why any assassin would use Dioxin as a murder weapon. As CodeBlueBlog said, right from the beginning, if we are to assume that there were someone whose intention was to kill Yushchenko, or even disfigure him, in no way could he depend on Dioxin to do either. Said Jean-Francois Narbonne, a professor of toxicology at the University of Bordeaux:

...dioxin -- although a highly dangerous poison that could be administered in tiny amounts -- would not be the assassin's natural weapon of choice

If they wanted to kill him, cyanide or a poison derived from a plant or bacteria would have been far more effective...

When you want to kill someone quickly, you use neurotoxins, substances which attack the tissues of the central nervous system, paralysing the target and stopping respiration and heartbeat.

This announcement does not change, by one iota the way I would approach this case or diagnose this case -- nor should it change the way any reader approaches a similar case or any similar situation in life.

Beginning tomorrow, I am going to show you why. Because the truth is, a diagnostician is obligated to adhere to the most likely diagnosis until that diagnosis is either proven wrong or diminishes in statistical relevance related to the next most likely diagnosis.

If people could learn THAT lesson, they would make better choices in their lives and live better lives. Because Viktor Yushchenko's diagnosis is a Lottery diagnosis. By that I mean that it's like seeing someone on television win the lottery and then going out and spending everything you have on lottery tickets. What happens? You lose all your money.

So I will explain MORE tomorrow -- after I give you a SERIOUS update on the Mary McClinton story. A story I will be getting back to with a sledgehammer, and I may fly to Seattle to confront the doctors at Virginia Mason Medical Center. If you have time tonight read about it here and here. Because I have NEW Information. Information culled by personal investigation. And it is going to get exciting, I think.

What happens if the next time you see a similar case you START from the proposition that this is poisoning? The patient dies from his much more likely disease.

Comments

[cardioNP]

Were the "here" and "here" re: the Mary Mcclinton story meant to be links? If so, they did not work.

[Sean]

Thanks for all the work you're doing trying to get to the truth about the Yuschenko story.

You're really a lone voice of reason in a cacaphony of illogic.

Keep it up! Worse case scenario is that the truth will come out after the election, and we'll be able to call all those sheep, well, "sheep" I guess.

Sean

[Mad House Madman]

first, seeing you give in to the diagnosis just because of a single blood test is sort of SAD. I mean, SO WHAT if his levels are 100,000 times the normal range. Not evryone is perfect you know. ;-}
it was fun though, reading your posts. great blog, your certainly one of my favorites.
Congrats on the award as well.

[JM]

Never got around to making this comment in one of your previous entries, but: considering the political context of the Ukraine, the classic horses/zebras analogy is inexact.

Given the inflated rate of accidents and mysterious illness among members of the political opposition, some caution should be exercised before dismissing anything as a coincidence. All those car crashes may not be a commentary on brake manufacturer quality control.

Commentary on the choice of dioxin (not mine):
http://www.corante.com/pipeline/archives/2004/12/15/dieoxin.php

[Pythagoras C]

DID VY POISON HIS BLOOD SAMPLE?

It is not hard, especially when the Vienna doctor overseeing his care (Dr. Korpan) is in reality his own guy ( http://trans-int.blogspot.com/2004/12/strange-case-of-dr-wicke-or-questions.html ). Obvious motive, plenty of opportunity.

The "dioxin poisoning" ubiquitous believers still make no effort to account for VY's severe case of acute pancreatitis. This diagnosis never previously reported as a dioxin poisoning complication in any of several cases, including the one where the highest ever blood dioxin concentration was found (notably, by doctors in Vienna! http://ehp.niehs.nih.gov/members/2001/109p865-869geusau/geusau-full.html ). WHY DID VY HAD PANCREATITIS? CBB's theory, alcohol, still appears the best bet to account for both pancreatitis and the rash.

[Julie]

Let's review and try to think logically:
Politkovskaya's book: Putin, Poison and My Struggle for Freedom gives us current evidence for poison being used against even minor personalities in Russian political warfare.
Markov's murder provides a historical context for SOP in the Russian security forces.
Now, as to context:
Whether or not a four-legged equine is more likely to be a horse or a zebra depends on where you are. If you are in the African savannah or the San Diego Zoo, it's more likely to be a zebra.
Political weapons differ from place to place. In this country, character assassination remains the method of choice. However, Lincoln, Garfield, Kennedy, and Reagan are examples of our own cultural preference for guns as the alternative tool. Russia appears to have chosen a weapon with a long record of success: Remember all those monarchs who had Royal Foodtasters? Poison is much more subtle than our gun: Not only is it noiseless, it's virtually impossible to discover who the poisoner is. This is a plus when you are committing murder (not suicide).
Finally, if you walk into your waiting room and see a woman with a swollen abdomen, what's your first thought?
May I suggest that your first thought is bound by the context: If your office is Obstetrics and the patient is 25, you think one thing. If your office is Oncology and she is 65, you think another.
VY's illness cannot be separated from the context of Russian and Ukranian politics. Given the history, it's much more likely that this dramatic decline in the candidate's health is related to political methodology than to unrelated causes. BTW, if all you had was the clinical picture, could you possibly imagine a man this sick getting out to campaign for office? Talk about context...

[Pythagoras C]

Julie, or anyone, how do you account for VY's severe case of acute pancreatitis? (here is his medical file from Rudolfinerhaus: http://www.razom.org.ua/en/news/2357/ ). Can you show an instance of pancreatitis among the several cases of dioxin poisoning reported? Or would you suggest that VY's pancreatitis was a concurrent second diagnosis unrelated to dioxin?

[nickpicker]

VY's a an almost typical case of a dissident voice in the former USSR being silenced by a deadly poison that leaves no traces to the client.

Only that VY is not a dissident but he's been party to the corrupt system for a long time. And he wasn't silenced at all. Actually, he walks around ranting even more than before. And the poison probably won't kill him. Actually, there's not a single report of a human being killed by dioxin. And all fingers point to Yanukovich, Kuchma, Putin, prominent figures not really hiding in the dark. And not only was the poison not deadly but VY's meds couldn't detect it when first symptoms showed. But VY's meds could identify the traces without doubt months later, because, as we all know, dioxin has the miraculous characteristic of increasing aggregation over time so that it becomes easier, not harder to find evidence for VY's poisoning. That's why the killers chose dioxin, because no one should ever discover that it wasn't the Kuchma-Yanukovich-Putin axis that did not kill him with a non-lethal substance.

[Jim Hu]

Here is a link to the report on previous cases that bracket the high levels seen in the VY sample:

http://ehp.niehs.nih.gov/members/2001/109p865-869geusau/geusau-full.html

Patient I did show some acute GI symptoms - no mention of anything with the pancreas.

Pubmed shows some nonalcoholic cases of pancreatitis associated with pentachlorophenol. I wouldn't be surprised if really high doses of dioxin could affect all kinds of symptoms and systems, and have different effects in different patients. Of course, since it's outside my field, surprising me isn't that hard.

[rhodeymark]

Hmmm - 100,000 units of TCDD, the *second* highest concentration of dioxin poisoning, and a compound that was a key ingredient in Agent Orange according to the AP. Yeah, VY spiked it into his own blood after that Bad Wodka™ bender. Sorry, Sean & Pythy... guess it's more crying in the wilderness for you zebra cowboys.
Doc, it was interesting stopping by, and I love the latest post about the (ahem) esteemed British Journal. Keep barking up them trees!

[kyan gadac]

"units" ?!!!!

[per]

CBB misses the point. If you give cyanide, neurotoxins, whatever, these will definitely kill; but it is pretty damn easy to make the diagnosis of poisoning.
With a corpse, a diagnosis of poisoning, the analytical techniques exist to enable a proof of poisoning.

By contrast, in this case, it took 3+ months to make the diagnosis, partly because the chloracne is a late onset symptom- there is tremendous inter-individual variation in susceptibility to chloracne.

There simply are not sufficient cases of people who had been poisoned with these amounts of tcdd to tell whether the pancreatitis is atypical or not.

But one other thing; vy had severe GI, liver and pancreas problems before the chloracne developed. If he had died at that stage, no-one would have considered dioxin poisoning as an explanation, and the tests for dioxin are sufficiently specialised they would never have been done.

That looks like it was nearly world-class poisoning to me.

per

[Pythagoras C]

TCDD NOT LETHAL, EASILY DETECTABLE ==> POOR POISON CHOICE
per, according to the scientific literature, nobody is known to have died acutely or subacutely after TCDD poisoning (even the risk for cancer, if any, is small). The only consistent sign is chloracne, which is easily suspected by experts and easily confirmed. For a prospective assassin, therefore, TCDD would be a rather dumb option.

THE LOOK OF CHLORACNE - NOT ON VICTOR'S FACE
Another problem with the "poisoning" theory is that VY's rash looks much more like an erythematous rash partially covered by make-up, rather than chloracne. Just look at some of VY's photos:
http://cnn.netscape.cnn.com/ns/news/photosearch.jsp?cap=Yushchenko
Chloracne lesions look really rough (e.g. http://dermnetnz.org/acne/chloracne.html . If you have full text medline access, see also http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=12850300 ). Their appearance does not change by the day, whereas VY's greenish facial patches look rather smooth and somewhat changed from day to day.

ALL SYMPTOMS COULD BE ALCOHOL SEQUELLAE
VY had beer, vodka and cognac on Sept. 5 (as per the NY Times: http://www.nytimes.com/2004/12/20/international/europe/20ukraine.html ) and probably on many other occasions too. As CBB has correctly pointed out, alcohol is the commonest cause of pancreatitis and of facial rashes of many types, including rosacea, which is probably what VY has.

WHAT ABOUT TCDD IN THE BLOOD SAMPLE?
If you ran for the presidency and the choice confronting you was between being exposed as alcohol abuser or "proving" that you were dioxin-poisoned by your enemies, what would you do? I would have little hesitation finding some TCDD and adding it to my privately drawn and handled blood sample.

WHAT THE MEDICAL AND LEGAL WORLD MUST DEMAND
2 Very simple medical actions:
(1) Examine the patient carefully. Reliable doctors must determine whether the greenish color is due to chloracne or make-up. Very easy.
(2) Get a new blood sample for TCDD confirmation. It should be drawn and handled under supervision by trustworthy medical personnel and sent to at least 2 different labs. Very easy.
VY is reportedly not cooperating with the investigation (see NY Times article above). One does not have to be a conspiracy buff to suspect why.

[per]

Well, Pythagoras C
I don't think you read my post very carefully, because you ignored most everything I said.
There is significant inter-individual variability in whether people get chloracne, and it only occurs weeks to months after dosing- as your reference explicitly states.
If you gave enough TCDD to be acutely lethal, it would still be a wasting type disease over several months, and death could well precede your only diagnostic indicator, chloracne.
I should also point out that you are now suggesting that the medics at Rudolfiner are - at the very least- complicit in adulteration and fraudulent analysis of a blood sample. I will bet my bottom dollar that would be a criminal offence.
No offense, but if I believe that, why should I believe the word of any medic who takes VY's blood ? Wouldn't it all be part of a - conspiracy ????
per

[Pythagoras C]

per, your point on the possibility of a poison causing death without detectable telltale signs is theoretically a valid one. However, in the the case of TCDD poisoning, no death has ever been reported in the medical literature, with or without chloracne, despite hundreds of cases examined. Therefore, a prospective assassin would be dumb to use TCDD on VY.
Concerning the responsibility of Rudolfinhaus in a highly probable blood sample fraud, if you are a medic and a family man at Rudolfinerhaus and VY's assistant comes to you with a blood sample telling you "take it to Amsterdam for dioxin test", you just shut up and do as you are told.

[per]

Pythagoras C
I appreciate your answer. As you point out, there are no documented deaths from dioxin. However, I can also point out that this is different from saying dioxin cannot kill you ! We know that doses of ~2mgs total cause severe illness. It doesn't take a lot of extrapolation to work out that higher doses will- at some dose- be fatal. For the record, we now that primates have an LD50 of~70-100 microgrammes/kg, so that's an expected human dose of 7mgs.
As regards the dumbness, I just don't see the logic there. I suspect that it is very easy to get poor absorption of high amounts of dioxin from food, and I don't have knowledge of how it was administered (in what), or how much.
I will also note the case of georgi markov, who was probably poisoned with abrin or ricin. I don't know if anyone did any human experiments beforehand- obviously it wouldn't pass ethical review these days- but someone guessed a lethal dose for human. Because of the poisoned umbrella hypothesis, it was later found out that several other eastern bloc emigres had also been killed in the same way. So there is some precedent for the use of unusual poisons by Eastern bloc countries.
Finally, if I was an Austrian doc, I would have some reservations about taking samples of dubious provenance, which may or may not be spiked, specially as I understand VY to be Ukrainian. Ain't nothing VY can do if the docs in Austria get put away for fraud/ malpractice. So my thoughts are that I think malpractice or fraud are extremely unlikely, and would have to involve the complicity of multiple professional people.
yours
per

[Pythagoras C]

per, your theoretical points on TCDD are well taken. In any case, it is not my intention to dwell on whether VY might have been poisoned by smart or by dumb people. My main point (originally CBB's) is that the only poison in his body was alcohol.
As for the reaction of Rudolfinerhaus doctors confronting a suspected "poisoning" fraud, there is the Wicke approach (resign) and the Zimpfer approach (look the other way and say whatever the tough guys want). You might have followed the former, but many people follow the latter. They are not medical role models, but they should be empathized with, not prosecuted for malpractice.

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