An inexorable course

Published : Sep 02, 2000 00:00 IST


P. RANGARAJAN KUMARAMANGALAM was an active participant in the monsoon session of Parliament but was admitted to the All India Institute of Medical Sciences (AIIMS) in New Delhi on August 13, before the session concluded, for investigation and treatment o f a persistent low-grade fever. When he slipped into a coma after suffering two cardiac arrests on August 16, there was widespread shock and disbelief. From then on the outlook only got steadily worse. Multiple organ failure and septicaemia were detected early, but these remained essentially symptomatic readings that did not go to the root of the problem. Three days after he lapsed into a coma, he was diagnosed as suffering from acute myeloid leukaemia.

The question has been raised whether timely diagnosis of his condition could have saved Kumaramangalam, who breathed his last at the AIIMS where his condition deteriorated at a rapid pace. Acute myeloid leukaemia, a type of blood cancer, and mylodysplast ic syndrome, which are characterised by dysfunctional bone marrow, were diagnosed. However, doctors at the AIIMS averred that the announcement of the diagnosis was not germane as the Minister was being treated for complications that had resulted from his basic malaise.

The history of the fever appeared a few months old, according to informed sources at the AIIMS. Kumaramangalam had gone to the Andaman and Nicobar Islands in March. He returned with a fever and apparently took some anti-malarial treatment on his own. The fever persisted. In April, he visited Indraprastha Apollo Hospitals in New Delhi, where he was investigated for fever. Among other things, a patch on the lungs was detected. A CT scan, bronchoscopy and a CT-guided fine needle aspiration cytology of the chest were done. He was treated with antibiotics and put on anti-malarial treatment even though there was no evidence of malaria. A urinary tract infection was also suspected. The drug regimen brought down the fever, following which he was discharged. Ku maramangalam was asked to return for follow-up treatment.

The fever returned some 10 days later but he did not go back to Apollo. On the advice of his family physician, he began to take a course of medication for tuberculosis (TB). He continued to take this treatment and did not undergo any other test. But his fever did not come down, and he lost 8 to 10 kg in weight. He complained of weakness, bodyaches and bone pain and it was in this state that he went to the AIIMS on August 11, seeking treatment as an out-patient.

After examination by an Associate Professor of Medicine, investigations were recommended as the cause of the fever was not known. Kumaramangalam was advised to have himself admitted to the hospital the following day but he expressed a wish to wait until August 13. A series of investigations was conducted including X-rays and a blood count. An X-ray of the chest showed no patch. This ruled out pneumonia but the total leucocyte count was low. He was told that detailed investigations, including bone marrow tests, would be done. This course was chosen on account of the low white blood cells count.

Bone marrow aspiration and biopsy were conducted the same day, August 13. Detailed blood tests were also done. The blood count had fallen further and it was only half of what normally the lowest level should be. The bone marrow test revealed some abnorma l cells, which were identified some days later in the biopsy as leukaemia cells. Kumaramangalam was then told that he had bone marrow abnormality. The biopsy reports were to take some time and he was told that he would get to know the result on August 16 or 17. But the doctors examining him had an inkling that it could be leukaemia. A rough diagnosis had already been done, which did not contradict the final biopsy results. The CT scan of the lung revealed nothing, though there were some lesions on the spleen.

On the night of August 14, Kumaramangalam complained of acute stomach ache and breathing difficulty. His blood pressure dropped and he was shifted to the intensive care unit where he was put on antibiotics and intravenous fluids. The antibiotics were mea nt to prevent the spread of infection in the body as his white blood cell count was very low. All through August 15, his condition continued to deteriorate, his blood pressure fell even lower and his breathing difficulty grew. He was then put on a ventil ator but there was no sign of improvement.

The next day, August 16, he suffered two cardiac arrests following which he was revived. His blood pressure plunged to dangerous levels despite a sufficiently high drug dose, and simultaneously his urine output decreased. Renal failure set in with septic aemic shock and his condition now was identified as one of multiple organ failure. The clotting mechanism had failed and he was being given replacement blood regularly. Meanwhile, the same day the biopsy results arrived and cancer cells were detected.

On August 16, a specialist faculty committee under Professor J.N. Pande, Head of the Department of Medicine, was constituted to review his clinical condition. Through the next two days, the condition of the Minister continued to be critical. He was on li fe-support systems. On August 17, he underwent dialysis and continued to be on life-support systems. This situation persisted until August 22, when he was declared to be "unresponsive to therapy". He was infused with high doses of drugs and he continued to be on artificial respiration and dialysis, until the end came on August 23.

Medical sources suggest that in retrospect, if a white blood cell count had been done much earlier, prior to his admission at the AIIMS, the diagnosis may have come up earlier. It appears that the WBC count was quite low despite the fact that the patient had an infection. Normally, in the event of an infection, the WBC count goes up. But it could be that it was not going up also because the infection was not serious enough, speculated some experts. The seriousness of the situation was not accurately gau ged.

The Union Government has constituted a team of medical experts to inquire into the whole course of medical treatment that was provided to Kumaramangalam. The report is expected by mid-September.

A NUMBER of tests done on Rangarajan Kumaramangalam at Indraprastha Apollo Hospital in April "clearly showed that there was no evidence even to suspect any blood disorder like leukaemia", according to Dr. Prathap C. Reddy, Chairman of the Apollo Hospital s Group. "Myeloid leukaemia can manifest even in 30 days," Dr. Reddy said. But there was a "long interval of 100 days" between his leaving Apollo Hospitals in April and his admission to the AIIMS in August. The tests done on Kumaramangalam at Apollo rule d out not only leukaemia but also tuberculosis.

"To blame Apollo for wrong diagnosis is not true and against all facts of the case... To say that we missed the diagnosis is baseless, untrue and unfair. Apollo Hospitals have done the maximum that a hospital anywhere in the world can do," he said.

Kumaramangalam was admitted to Apollo in New Delhi on August 14 with a history of fever for two weeks and he had already taken antibiotics. He had a patch in his lungs. There was high erythrocyte sedimentation rate (ESR). "When they (the patch and the hi gh ESR) are there, we automatically think of TB or cancer," Dr. Reddy said. Later, the ESR count came down. Blood tests, a CT scan, bronchoscopy and biopsy of the patch in the lungs were done. Dr. Reddy said, "Tuberculosis or cancer was ruled out... Now they say Kumaramangalam had myeloid leukaemia. There is no way we could have diagnosed leukaemia or done tests for leukaemia because four months ago nobody could miss a diagnosis for leukaemia in a hospital like the Apollo."

The white blood cells count would be very high in a case of leukaemia. But in Kumaramangalam's case, it was about 5,000 - which was normal. Besides, leukaemia would always show abnormal blood cells. "Not even in a single smear we saw abnormal blood cells ," Dr. Reddy said. The third factor is, platelets in leukaemia would drop below 20,000 from the range of 1.5 lakhs in a normal person. But here the platelets level was normal all long. Besides, the biopsy of the patch in the lungs did not show any oozing of blood. In leukaemia, there was a tendency to bleed. Dr. Reddy said, "These four factors clearly showed that there was no evidence even to suspect any blood disorder like leukaemia."

Dr. Reddy said that since the Minister smoked, a biopsy of the patch in his lungs was done, which again showed that he did not have lung cancer. Bronchoscopy of his lungs was done to look for cancer cells. Bronchoscopy enabled doctors to examine visually whether there was tumour for cancer or inflammation for TB. Then a biopsy of the tumour or inflammation would be done. Fluid from the lungs was aspirated and sent for tests. The result was negative. The CT scan did not show any evidence of cancer. " Th ese three ruled out both TB and malignancy of lungs... So what they are blaming us for is wrong," Dr. Reddy said.

DR. RAMESH B.V. NIMMAGADDA, Director, Medical Oncology, Apollo Speciality Hospitals, Chennai, said that myeloid leukaemia grows very fast. When Kumaramangalam came back in May to the outpatient dapartment of Apollo, a blood test was done, which showed th at his haemoglobin had increased. It meant that his bone marrow was all right. "At that point, there was no reason for anybody to think of a bone marrow test," Dr. Nimmagadda said. The patient's temperature and ESR level had come down. So there was no re ason to suspect leukaemia. Dr. Nimmagadda said that doctors at Apollo were looking for infection and he was empirically treated with antibiotics. "But no specific infection was found."

Kumaramangalam was discharged on April 23 because Parliament was in session. Copies of his records were sent to the leading physician Dr. Farokh Udwadia in Mumbai and he said the diagnosis was perfect, Dr. Prathap Reddy said. Also, two days after his dis charge, copies of his medical records were sent to Mass General Hospital, Boston. Besides, a teleconference was held involving experts in Boston, doctors at Delhi Apollo and Kumaramangalam himself, who participated from his home. The specialists from Bos ton agreed with the line of management at Apollo. They advised periodical follow-up. But he never came back to see the treating physicians, Dr. Prasad Rao or Dr. Ajay Lal, Dr. Prathap Reddy said. Dr. Prasad Rao has 20 years' experience in medicine. Dr. L al is a specialist in lung diseases.

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