Yushchenko's illness: What the doctors say

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By Elisabeth Rosenthal International Herald Tribune Saturday, December 4, 2004

VIENNA When the once-strapping, telegenic man was wheeled in through the sliding glass doors of the plush Rudolfinerhaus Hospital in early September, he was suddenly and 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 and 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 Yushchenko, Ukraine's opposition leader, checked out against doctors' advice, determined to return to the business of winning the November election in Ukraine.

But in just two weeks he was again at Rudolfinerhaus, crippled by a new and even more elusive problem: back pain so excruciating it took huge doses of morphine to control and almost necessitated that he be put on a ventilator. Once again, a week of testing found no medical explanation.

Yushchenko and his doctors agreed upon a risky plan: doctors threaded a small tube through the skin of his upper back, into his spinal canal, so that the patient could campaign, while receiving constant pain-killing medication.

And so it was that 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.

"I went with him because I had serious security concerns and I wanted to make sure he was handled properly," said Dr. Michael Zimpfer, medical director at the Vienna hospital, who supervised the case. Indeed, the doctors had become increasingly suspicious that foul play, particularly an unusual poisoning, could be the cause of their patient's problems, a charge that Gerashchenko repeated.

In interviews this week, the Austrian doctors were quick to stress that scientifically they cannot say that the candidate was poisoned. Tests for common toxins have been negative. But the medical team was so concerned about the possible presence of an unconventional agent that they consulted biological and chemical weapons experts.

"A poisoning without the poison is like a murder without a gun," 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 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."

Gerashchenko said Yushchenko considered some aspects of his health a private matter, but added that he 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 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 high-stakes tussle for power that has pitted the West against Russia?

In September, Yushchenko immediately charged that he was 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. Note my articulation. This is one-hundredth of the problems that I've had," Yushchenko told the Ukrainian Parliament on Sept.21, after his first stint in the Vienna hospital. "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 Yushchenko's hospitalization was bad sushi or too much alcohol, although doctors here said there was no evidence of that. But some doctors point out that it is still conceivable that Yushchenko had the bad luck to develop a rare illness, difficult to diagnose, at the height of the campaign.

The issue of Yushchenko's medical state 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 tears.

Last week a prominent British toxicologist, Dr. John Henry, suggested that Yushchenko's symptoms were consistent with dioxin poisoning, which causes a severe form of acne called chloracne. This condition occurs months to years after exposure, when the body seeks to eliminate residual 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 Yushchenko for dioxin in part because his skin changes were much milder in September than they are now. Also, they said, the candidate refused a biopsy of his face because he did not want to campaign with stitches. But dioxin and related toxins are detectable in the body years after exposure. Gerashchenko said such tests had still not been performed.

Oddly, the only recently reported cases of dioxin poisoning were also seen in Vienna, in 1998, when two secretaries at an Austrian textile plant arrived at the University of Vienna with severe facial disfiguration like Yushchenko's - as well as nausea, vomiting and abdominal pain.

Although a criminal investigation was started, it remained unclear whether the two had been poisoned or somehow exposed through their work, according to a 2001 report by Dr. Alexandra Geusau in Environmental Health Perspectives, a medical journal.

Before that, hundreds of people had been exposed during the mid-1960s and 1970s, in two separate incidents in Japan and Taiwan, after dioxin contaminated bottles of cooking oil. A number of patients experienced an acne-like eruption, skin discoloration and tearing for several years after the exposure, according to Japanese accounts.

That being said, some doctors - who spoke on condition of anonymity because they had no direct contact with Yushchenko - said that he could still be suffering from an unusual immune disease that could cause many of the same symptoms. One, called scleromyxedema, is an extremely rare progressive disorder that produces facial symptoms much like 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 Zimpfer said Yushchenko's skin nodules no longer resembled that disease.

Political intrigue is not the norm at Rudolfinerhaus, an upscale private hospital that caters to wealthy Austrians and foreigners. Because of cultural ties between western Ukraine and Austria, many upscale Ukrainians come here to have babies and for other medical treatment.

Zimpfer, the medical chief at Rudolfinerhaus, provided extensive details of Yushchenko's hospitalizations. The candidate arrived Sept.10 at the hospital, severely ill and unable to walk, after five days of terrible abdominal pain. Initial testing showed that he had a high white cell count, as well as elevated liver and pancreas enzymes suggesting inflammation of those organs. The numbers were a cause for concern, but not specific for any one disease.

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, though for no clear reason. Internal examinations of the intestine using an endoscope found that he had ulcerations - essentially bleeding abrasions - of the stomach and throughout his intestine and bowel as well. Ulcers are typically not spread out in this way.

The doctors gave him supportive care, like intravenous fluid and a restricted food intake to rest the digestive tract. As the lab values started to head downward and 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-bore intravenous line into the candidate's chest and essentially nearly anesthetize him with huge doses of opiates. Because opiates depress respiratory functions, his breathing rate slowed, and the candidate was kept in a monitored unit.

Further medicine would have required that Yushchenko be placed on a respirator, Zimpfer said.

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 specifically to the nerves in the back without compromising the candidate's mental abilities.

Epidural catheters are common for pain relief in childbirth, but they are far riskier when they are placed for the long term and in the upper back, closer to the brain and vital nerves.

Yushchenko was discharged three days later, with the retinue of doctors and cartons of medical supplies. He was still on "plenty" of medication, and a colleague of Zimpfer remained in Ukraine to carry out his medical program for several days.

Zimpfer said the medical team was treated politely in Kiev. "I had a number of concerns in light of how heated the situation in Ukraine was even then, and in light of the disputes between the two parties about the cause of his illness," Zimpfer said. "But after a lot of soul-searching, I decided I had to go myself. I was the captain and I could not desert the ship."





Steven Lee Myers of The New York Times reported from Kiev.