Da NYTkraine Candidate's Illness Stumps Doctors
By ELISABETH ROSENTHAL
International Herald Tribune
Published: December 4, 2004
VIENNA, Dec. 2 - When the once-robust, telegenic man was wheeled in through the sliding glass doors of the plush Rudolfinerhaus hospital in early September, he was severely ill, conscious but groggy and complaining of terrible abdominal pain. Multiple blood tests were abnormal, doctors here say; his skin was covered with odd-looking lesions; his digestive tract was dotted with ulcers from top to bottom.
Europe's most illustrious doctors were stumped; the patient's many symptoms defied a unifying diagnosis. Eight days later, Viktor A. Yushchenko, Ukraine's opposition leader, checked out against medical advice, determined to return to the business of winning the presidential election in Ukraine.
In less than two weeks he was back, crippled by excruciating back pain that required such huge doses of morphine to control that he almost ended up on a ventilator. Once again, a week of testing found no medical explanation.
Mr. Yushchenko and his doctors agreed on a risky plan: Doctors threaded a small tube through the skin of his upper back, into his spinal canal, so he could receive constant pain-killing medication while campaigning.
And so it was that Mr. Yushchenko flew back to Kiev with a catheter lodged in his back, escorted by a team of Austria's most elite doctors. He campaigned with the tube in place for a week, attending several large rallies, according to his press secretary, Irina Gerashchenko.
Dr. Michael Zimpfer, the medical director at the hospital here, personally supervised Mr. Yushchenko. "I went with him because I had serious security concerns and I wanted to make sure he was handled properly," he said. Indeed, the doctors had become increasingly suspicious that foul play, possibly an unusual poisoning, could be the cause of their patient's problems, a charge that Ms. Gerashchenko repeated.
In interviews this week, the Austrian doctors were quick to emphasize that, scientifically, they could not say that the candidate had been poisoned. They tested only for common agents, and found none. But the medical team became so concerned about the possibility of an unconventional agent that they consulted biological and chemical weapons experts.
"A poisoning without the poison is like a murder without a gun," Dr. Zimpfer said. "But if someone said to me, 'Look what we found!' I wouldn't be at all surprised.
"In this case, absence of evidence is not evidence of absence," he said.
He continued: "As I've said to the family, if this is a poisoning, it's going to be very tricky and tough to discover. They are not going to use some regular household agent."
Ms. Gerashchenko said Mr. Yushchenko was continuing to receive treatment from Ukrainian doctors. "He feels much better than he did two months ago, but he's far from ideal," she said.
New details of Mr. Yushchenko's hospital admissions in Vienna raise disturbing questions: Was the candidate poisoned or infected with some biological agent, and, if so, with what? What is his current state of health, in the middle of a pivotal battle for power?
In September, Mr. Yushchenko immediately said he had been poisoned, but that charge was lost among the heated political debates and demonstrations in the final weeks of the campaign, which culminated in the disputed election.
"Look at my face," Mr. Yushchenko told the Ukrainian Parliament on Sept. 21, after his first stint in the Vienna hospital. "Note my articulation. This is one-hundredth of the problems that I've had. This is not a problem of political cuisine as such. We are talking about the Ukrainian political kitchen where assassinations are ordered."
Opponents dismissively suggested that the cause of Mr. Yushchenko's hospitalization was bad sushi or too much alcohol; doctors here said there was no evidence of either. But some doctors point out that it is conceivable Mr. Yushchenko had the bad luck to develop a rare illness, difficult to diagnose, at the height of the campaign.
The issue has persisted because of the obvious disfigurement and discoloration of his face, which is swollen and pocked with large bumps and cysts, and is a dusky grayish color. The left eye is bloodshot and sometimes waters.
Last week a British toxicologist, Dr. John Henry, suggested that Mr. Yushchenko's symptoms were consistent with dioxin poisoning, which causes a severe form of acne called chloracne. The condition occurs months to years after exposure, when the body seeks to eliminate residue of the chemical through the skin. But cases of dioxin poisoning are extremely rare. Scientists debate whether a huge one-time dose could be delivered as a poison.
Doctors at Rudolfinerhaus said they did not test Mr. Yushchenko for dioxin in part because his skin changes were much milder in September, not suggestive of dioxin. The candidate refused a biopsy of his face - which doctors suggested to try to narrow down the causes - because he did not want to campaign with stitches. But dioxin and related toxic chemicals are detectable in the body years after exposure. Ms. Gerashchenko said tests for such substances had still not been performed.
Some doctors not involved with the Yushchenko case, consulted for their opinions, said he could be suffering from an unusual immune disease. Scleromyxedema, for instance, is an extremely rare progressive disorder that produces facial symptoms much like Mr. Yushchenko's. But it is not known to produce pain.
Dermatologists at Rudolfinerhaus initially suggested that the facial lesions could represent a slightly unusual case of a well-known condition called rosacea, where the face becomes swollen and lumpy. But Dr. Zimpfer said Mr. Yushchenko's skin nodules no longer indicated that disease.
Political intrigue is not the norm at Rudolfinerhaus, an elite private hospital that caters to wealthy Austrians and foreigners.
Dr. Zimpfer provided extensive details of Mr. Yushchenko's hospitalizations. He arrived first on Sept. 10, severely ill and unable to walk, after five days of terrible abdominal pain. Initial testing showed that he had a high white-cell count and elevated liver and pancreas enzymes, suggesting inflammation of those organs. His tests were negative for all the obvious possibilities, like hepatitis caused by a virus.
Scans showed that his liver, pancreas and intestine were, indeed, swollen. Internal examinations of the intestine using an endoscope found he had ulcerations - essentially bleeding abrasions - of the stomach and throughout his intestine and bowel as well. Ulcers are typically not spread out in that way.
The doctors gave him supportive care, like intravenous fluid and a restricted food intake to rest the digestive tract. As he gradually recovered strength, he opted to get back to the campaign trail. Already, doctors noticed that he was developing odd lesions on his face and trunk.
Ten days later, the candidate returned, after three days of what he called excruciating back pain. Its source was again a mystery, since related lab tests and scans were normal.
The pain was so severe that doctors had to place a large intravenous line into Mr. Yushchenko's chest and essentially nearly anesthetize him with huge doses of opiates. Because opiates depress respiratory functions, his breathing rate slowed, and his vital signs had to be constantly monitored. More medicine would have required that Mr. Yushchenko be placed on a respirator, Dr. Zimpfer said.
Mr. Yushchenko and his doctors made a difficult choice: They decided to place an epidural catheter between his shoulder blades into the membranes of the upper spine so that medicines could be delivered to the nerves in his back without compromising his mental abilities.
Epidural catheters are common for pain relief in childbirth, but they are far riskier when they are placed for longer periods and in the upper back, closer to the brain and vital nerves.
Mr. Yushchenko was discharged three days later, leaving with a retinue of doctors and cartons of medical supplies. He was still on "plenty" of medication, said Dr. Zimpfer. They arrived in Ukraine, and, after a few hours, Dr. Zimpfer returned to Vienna, leaving Mr. Yushchenko in the care of another Austrian doctor.
"He was severely ill, but this does not all add up to a single disease or even a known syndrome," Dr. Zimpfer said. "At this point his diagnosis is just a description of all his symptoms."
Steven Lee Myers of The New York Times contributed reporting from Kiev, Ukraine, for this article.
The KGB has plenty of experience with poisons.
Have a very nice day.
-fgalkin
-- Asuka
Heaven forbid we speculate and draw some lines to some old culprits.
I like the sentence. Imagine whatever you want, then say: "Absence of evidence is not evidence of absence".