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Palestinian Cabinet Issues Medical Report on Arafat's Death, Cause Still Unknown

Posted on: Saturday, 15 October 2005, 12:00 CDT

"Text" of a Palestinian National Authority cabinet statement on 12 October 2005 on the study by the PNA fact-finding committee of the medical file of the late PNA President Yasir Arafat and on the medical report signed by Dr B. Pats of Percy Military Hospital in France. WAFA headline: "Preliminary results of the fact-finding committee on the death of martyr President Yasir Arafat", published on Palestinian news agency Wafa website on 12 October

Ramallah: The cabinet today concluded that the medical file of the late martyr, Yasir Arafat, should remain open, so that the whole truth can be known, including the necessary explanations of the medical aspects mentioned in the committee's report.

In a statement at the end of its meetings in Ramallah on the West Bank, the cabinet noted that keeping the file open will continue to be the right of our Palestinian people and the right and duty of the Palestinian National Authority [PNA], in view of the file's great importance.

The fact-finding committee charged with following up the martyr's medical file has carried out a study of the circumstances of his death. It says the cause of death is severe inter-cranial haemorrhage ending a clinical case that combined several symptoms that were not possible to explain within the framework of nosology [classification of diseases], despite the fact that a great number of medical experts were consulted and all tests were carried out.

Following is the text of the cabinet statement on the matter and on the medical report:

The fact-finding committee charged with the medical file of the martyr [PNA] President Yasir Arafat has studied the circumstances of the death of the president-leader and has completed its task. It studied the French medical report and the Palestinian medical report. It consulted and held lengthy discussions with a number of physicians and other parties concerned and submitted the report on its tasks to the cabinet on 12 October 2005.

The report reviewed in detail the medical condition of the president-leader Yasir Arafat from 12 October 2004 until his death on 11 November 2004, including the medical tests and treatment that took place in Ramallah and those administered at Percy Military Hospital [in France].

The report says the cause of death is severe inter-cranial haemorrhage that ended a clinical case which combined several symptoms that were not possible to explain within the framework of nosology, despite the fact that a great number of medical experts were consulted and all tests were carried out.

Thus the physicians - each a specialist in his field - were not able to establish a known cause or disease that leads to such a clinical case, which ultimately led to the death of President Yasir Arafat. The committee concluded that medicine or other surrounding circumstances may be able in the future to reveal the cause of President Yasir Arafat's clinical case.

In accordance with the above, the cabinet concluded that this highly important file should remain open until the whole truth is known, including the necessary explanations of the medical aspects to which the committee's report refers, as that will continue to be the right of the Palestinian people and the right and duty of the PNA.

[Prime Minister] Ahmad Quray (Abu-Ala): The medical history was taken from Dr Al-Daqqah, [Arafat's] private physician, and Dr Hantati, the neurologist in Tunis, and the family, and we obtained [the results of] the medical tests from the Communite Hospital in Tunis.

A 75-year-old man, who has not suffered from important health problems or diseases in the past, suddenly became sick in his digestive system four hours after having dinner on 12 October 2004. He began to complain of symptoms such as fatigue, nausea and abdominal pain, without a rise in temperature. The symptoms continued, together with liquid diarrhoea without blood or mucus, accompanied by a feeling of exhaustion, loss of appetite and a loss of weight - as much as three kilograms - in the course of two weeks.

Preliminary tests that were carried out showed that the haemoglobin was normal: the number of white blood cells was 12,300 (normal up to 10,000), and the number of blood platelets was 177,000 (normal).

The symptoms continued until 18 October 2004. Tests began to show a fall in the number of blood platelets, without problems in the haemoglobin or the white blood cells, with a slight rise in liver enzymes, without a rise in bilirubin. He underwent the following tests in Ramallah and Tunis to find out the cause of his illness:

1. A culture of the blood, urine and stool, to identify germs or microorganisms.

2. Tests for various types of viruses.

3. Gastroscopy and colonoscopy.

4. Ultrasound of the abdomen.

5. Lumber puncture.

6. A study of the immunity.

All tests were negative.

- On 20 October 2004, the blood platelet count was 53,000 and the bone marrow test was carried out in Tunis was normal in general, but an increasing number of Macrophages 1 began to appear.

- On 26 October 2004, the illness continued and the blood platelet count was 46,000. He was given gama-globulin in high doses, in case there may be auto-immunity to deficiency in platelets. However, on the following day a disorder in the consciousness began, with drowsiness, without weakness or inflammation of the meninges. The neurological test was normal. The globulin was discontinued and he was given cortisone for the same consideration: self-immunity to deficiency in platelets and the presence of Macrophages in the marrow on 27 October 2004. However, on 28 October 2004 the blood platelet count was 26,000 and 6 six of platelets were transfused. However, the situation in the digestive system persisted, without a rise in temperature or a rise in the signs of laboratory inflection, with general weakness which rendered him bed-ridden.

- On 29 October 2004, he was moved to France. On being admitted to hospital, his clinical condition was as follows: temperature, blood pressure and pulse were normal, and oxygen in the blood was 100 per cent.

* Tired and confined to bed, with slowness in viscerosensory response, without confusion and with a small degree of lack of attention. However, this improved after several hours and his responses were balanced.

* Neurological test was normal and there was no haemorrhage under the skin or the mucus membranes, and there was no sign of thrombosis in the veins or deficiency in perfusion.

* Chest and heart were normal.

* Rumbling in the stomach with some pain, and there is no hepatosplenomegaly and no enlargement of the lymphatic glands.

* Urine was normal, but there was excretion of fluid without faeces.

* The tests carried out showed that the haemoglobin was normal (15.6).

* The appearance of red blood cells was normal, without the presence of disfigured or immature cells; a rise in the white blood cells, platelets count was 54,000. There were no microscopic parasites in the blood.

* Studies on the coagulation of the blood showed disturbances in some of the elements of bleeding indications PTT 71, PT36 per cent a second (normal is 32); deficiency of 0.6 Fibriyen (normal 4.5-2); deficiency in the elements connected with Vitamin K, especially Anithrombin III, 17 per cent FV49 per cent. There was a great increase in the factors connected with disturbance in coagulation that had spread FDP DIC more than 20, D-Dimers.

* Liver function showed a rise in bilirubin.

* Laboratory inflammation signs ESR, CRP normal.

* Thyroid gland hormones and cotisol hormone [?cortisone] normal.

All tests were carried out to identify any stomach or bacterial disease on his arrival and included blood, urine, stool and marrow cultures, with a study of parasites, viruses and tuberculosis, but did not show any cause and the results were negative.

A study of the stool test: water without faeces, white blood cells and rarely Eosinophils.

A study of the marrow: Rich and all the cells are very full. Components of the blood platelets are normal, but Macrophages represent one per cent, with Hemophagocyte activity. There are no primary cells and no cells that are not fully grown in the marrow, or cells from outside the marrow. There are no parasitic elements.

Immunity studies: There is no numerical change in the growth of lymphatic cells b or t.

* Coombs test positive.

* Complement deficiency.

* Tumour marker study: all negative.

Radiology tests:

* CT Scan of the brain: normal.

* CT Scan of the chest: normal.

* CT Scan of the abdomen: Thickness in the mucus membrane of the stomach, duodenum and colon. The spleen, pancreas, kidneys, liver and lymph glands: all normal.

* Magnetic Resonance Imaging [MRI] of the brain: No haemorrhage or clot.

After analysing the preliminary date resulting from the tests and the clinical case, the physicians tended to conclude there are syndromes:

* Gastrointestinal syndrome without evidence of inflammation, tumours or viruses.

* Severe blood clotting disorders, DIC, syndrome which had posed a problem from the beginning, with regard to knowing its cause and the severity of DIC control over the atypical clinical situation, that is not compatible with the clotting of small blood vessels, with no evidence from tests of any tumour disease.

* Macrophages in the bone marrow, without the existence of the syndrome activating the systematic macrophages. The macrophages are only in the marrow and not in the body, because when they are in the latter they are accompanied by a rise in temperature and enlargement of the liver, spleen and the lymph glands.

* The possibility of the existence of systemic auto-immunity is small because the immunity tests conducted in Tunisia and France were normal except for a fall in complement factors C3 and C4.

- The situation developed during the period from 29 October 2004 to 3 November 2004 as follows:

* He was placed on the necessary treatment, antibiotics, nutrition, compensating for fluids and salts, cortisone and zoverax. A slight improvement occurred in the general condition and there was improvement in his eating as well as in his state of apathy, and he moved in the room.

* On repeating the tests, the results of the laboratory tests for infectious diseases were all normal, with no rise in temperature and no accompanying inflammatory signs.

* Disorder of the blood clotting did not improve or recede, with no clinical signs of DIC complications or bleeding beneath the skin or the mucus membrane.

* Liver problems became more acute with the rise in bilirubin from 76 (normal 5-17) on 29 October 2004 to 218 on 2 November 2004, most of which is direct bilirubin, Cholestasis, with the stability of the enzymes of the liver cells and alkalinphosphates, and a small rise in the enzyme LDH. When the patient was admitted the Ferretin was close to normal, but there was a rise in ammonia 80-200 (the normal is less than 50).

* The neurological condition deteriorated as of 2 November 2004 from apathy to confusion, although the clinical examination did not show any clear disorder. CT scan of the brain was normal.

* On the following day, 3 November 2004, his condition deteriorated without any explanation and he went into a coma. An electroencephalogram [EEG] showed spreading slowness in brain activity with slow waves, without any localization.

* He was admitted to the Intensive Care Unit on 3 November 2004, and GCS was 7, while normal is 15.

* All previous tests were repeated with the following results:

Platelets 30,000; white blood cells 15,000; bleeding signs PTT112, clotting signs PT 41 per cent (normal 32); increase in the signs of the disorder of the spreading clot FDP, DIC,D-Dimers; continued disorder of the clot without cause.

- Sample of the bone marrow, lumber puncture.

- Gastroscopy and biopsies of the stomach and duodenum.

- Ultrasound of the abdomen.

All were negative and did not show any reason for the deterioration of the clinical situation. In the absence of any signs of infections or tumours, theories were postulated to explain the disorder of the clotting and the liver. He was given treatment accordingly, such as heparin and vitamin K, but they were discontinued because of bleeding in the stomach.

- On 6 November 2004 he began to suffer from kidney failure although the vital signs were stable. His neurological condition deteriorated and an MRI of the brain was carried out on 8 November 2004 but it did not explain the coma.

- On 9 November 2004 the EEG was shown to be flat. He underwent tests for toxic substances and radioactive substances and the medical consortium did not determine toxic substances examined. Throughout his period of illness his temperature or CRP, inflammation index, did not rise. All cultures of bacterial or viral substances, including the HIV AIDS virus, were negative.

- On 11 November 2004 he died of severe brain haemorrhage.

Conclusion:

President Yasir Arafat died on the 13th day after his admission to the Paris military hospital and on the 8th day after his admission to the Intensive Care Unit of a severe brain haemorrhage. The brain haemorrhage ended a situation over which discussions and consultations were taking place as to the reason why it occurred. This clinical case combines the following syndromes:

- The digestive system syndrome: The medical condition began 30 days earlier in the form of gastroenteritis.

- A syndrome related to the blood system that combined a deficiency in the platelets and acute spread of clotting in the vessels and phagocytosis of the marrow cells separate from any phagocytic activity in the blood vessels outside the marrow.

- Jaundice resulting from biliary recumbence [high bilirubin].

- The digestive system syndrome was in a state of undulant stupor and then in deep coma although a great number of experts were consulted, each in his own field. All the tests that were carried out did not explain those syndromes within the framework of nosology.

Signed: Dr B. Pats, head of Percy Military Hospital departments.

The tests that were carried out, with the exception of frequent routine tests of the blood, sugar, urine, stool, liver, salts, fats, organic chemicals, blood gases and hormones:

1. Tests on clotting and clotting factors.

2. Several biopsies of the spinal medulla in Ramallah, Tunisia and France.

3. Lumber puncture biopsies.

4. Repeated cultures of the blood, stool, urine, nose, throat, the trachea, the marrow and the spinal fluid, and a study of the bacteria and microorganisms.

5. Viruses, including HIV (AIDS): negative.

6. Tumour markers.

7. Toxins.

8. Gastroscopy and colonoscopy several times, with biopsies.

9. Radiology, several times:

- Ultrasound of the abdomen.

- CT scan of the brain, chest, abdomen and pelvis.

- MRI of the brain, chest and abdomen.

10. EEG of the brain.

Microbes, microorganisms, parasites and viruses:

Leptospira, Clamydia Pneumonia, Mycoplasrna, Leishmania, VDRL. Yersinia TPHA. AFB, HIV Retrovirous, HIV Rotaviras, Enterovirus, Adenovirus, CMV, Herpes Human Type and Parvovirus, Herpes Simplex, Whippelli, HIA Campylobacter, Rickettsia, Bartonella, Tularemic, P.F.Q., Gangliose, Histoplama, Clostridium Fificile, Salmonla, Shifella, Campylobacter, Yersinia, Malaria, Antifen HRP2, Frottis Sanfuin, Asperfillus, Coxiella Burretti. [All words in this paragraph as received in Latin].

Immunity tests:

Anticytoplasrnic polynuc, ANA, AMA, AS. Musle, Gastric Anticellular, IGM, IGG, Anticellular Purkenji, Anti-H4: IFIC, Antiendoplasmic Reticulum, IFI, Anti-RI. [All words in this paragraph as received in Latin (with possible typos)].

Comment:

The disease entered the body via the digestive system several hours after the patient ate dinner on 12 October 2004, according to the French report, or on 11 October 2004 according to the report of the Palestinian medical team in Ramallah. The disease caused disorder and severe irritation of the digestive system. Then a series of other disorders occurred, beginning with the bone marrow which led to a deficiency in the platelets and the appearance of macrophages only in the marrow. The disorder led to a blood clot, and then pathological signs began to appear in the liver with a rise in the bilirubin. Finally, there was a disorder in the nervous system, from apathy to a complete coma, then death as a result of a sever haemorrhage in the brain.

The clinical condition was deteriorating constantly with periods of improvement followed by increased deterioration. All treatment based on the theories regarding the reason for the occurrence of the disease did not succeed in stopping the continuing deterioration. Therefore, all the tests that were carried out to establish the cause - be they laboratory, radiological, laparoscopic or other - were negative, and did not show any positive cause, be it bacterial, inflammatory, parasitic, viral - including the AIDS virus - tumour, auto-immunity or toxic from the substances examined.

The team of physicians, each a specialist in his field, were not able to identify a cause or a known disease that led to the clinical case that ultimately led to death. Medicine, or other surrounding circumstances, may reveal the cause of the occurrence of such a clinical case in the future.

Source: BBC Monitoring Middle East

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