Why Did She Die?

For almost three months after she died, it had been a puzzle to me what exactly caused her death.

In the last 30 minutes, she had acute atrial fibrillation which led to a cardiac arrest. That much was clear.

But even the attending cardiac surgeon was not sure about the reasons why such an acute atrial fibrillation had happened because she had not had it before, and even all attempts to defibrillate her failed.

The cardiac surgeon put forward three possible reasons. One, her heart might have found it difficult to pump blood because of the dilated arch. Two, stopping of the anticoagulants could have resulted in the atrial fibrillation. Or three, there was a mention about a deformed, discontinuous stent in her ascending aorta in the CT scan, and the doctor felt it might have had a role to play in the atrial fibrillation.

I did a reasonable amount of research post her death with all her medical records and based on those, I could with reasonable confidence eliminate the first two. Her arch had been dilated for over five years and it was hence unlikely that that could have all of a sudden burdened heart. Amma was taking anticoagulants not for atrial fibrillation (as many patients do), but because she was at risk for pulmonary embolism (blood clot in lungs). Stopping of anticoagulants alone was thus unlikely to have resulted in such an extreme degree of atrial fibrillation.

That left me only with the third alternative – the deformed and discontinuous stent in her ascending aorta. I had no clue what that meant or how it could have resulted in an atrial fibrillation.

I almost gave up trying to figure out why exactly she died, until I came across an interesting term while reading something unrelated. The term was bacteremia in which a bacterial infection enters your blood.

Something clicked in my brain – amma had had an infection in her feet about a month and half before she died. It was the third time she had had a similar infection in the previous one year, and as I administered her the same medications that were prescribed the earlier two times. Similar to those times, she had recovered in about a week.

But this hint made me put down a complete list of symptoms and some rather strange things that happened to her in the month prior to her death. Here is the list.

It all started about a week after she recovered from the infection in her feet – which was about five weeks before she died.

  • Shooting pains in her feet 2-3 times a day for 3 days, about four weeks prior to her death
  • Unusually urgent hunger, sometimes during middle of the night (final two weeks)
  • Neck pain, but only while sitting and walking and not while lying down (about 10 days)
  • Relatively low BP and high heart rate (final 10 days)
  • Dark brown stools (not tarry or black, just dark brown – last 5 days)
  • Leg cramps while walking (final 4 days)
  • Extraordinary amount of sound sleep, (last 4 days)

Fig 53: Amma’s symptoms – some of them unusual – in her final 30 days

And, to add to the above, was the fact that her hemoglobin level did not increase at all even after she was transfused two units of blood at the hospital.

Except for her neck pain and low BP, others were quite unique for her and I had witnessed them before. Except for her dark brown stools, nothing really worried me. Things like her unusual hunger in the middle of night sounded bizarre, but not worrisome really. I could not really explain the shooting pains in her legs, but as he had been having leg pain owing to restless leg syndrome, I naturally put it down to an extension of that.

It really felt like a Agatha Christie mystery to figure out why she died with all the above confusing points, along with what the cardiac surgeon had said.

I decided to somehow crack the mystery, and for that, I had to start somewhere. I decided to start with her foot infection a month prior to her death.

I asked myself: What causes such foot infection. A detailed search revealed that she had most likely been ##, an infection due to Staphylococcus aureus (let’s call it staph for short). I then asked myself: What happens if staph enters the blood? Literature indicated that such bacteremia would have resulted in chills and fevers. More importantly, in unfortunate cases, the staph travelling in the blood could lodge itself in many different parts of the body, including the heart valves, especially in cases where there was an artificial valve implanted. The staph could also cause pain in other parts where it finds refuge, for instance the top of the spine.

Amma did not have any valve replacement. But her persistent neck pain seemed to indicate that it could have been because of the staph. It did not give me any clue as to how she could have died due to this, though.

Another clue presented itself. And that had to do with ulcers. Interestingly, for some old people, ulcers do not result in pain but result in huge pangs of hunger. This was getting interesting. So, amma quite likely had an ulcer, and that also explained the gradual internal bleeding. But why did she get an ulcer?

The staph enters the story again. One of the two medications that the doctor had prescribed for the bacterial infection is what is generally called an NSAID – a non-steroidal anti-inflammatory drug. While she had taken only low doses of this drug, in cases where an NSAID was taken along with an anticoagulant, the drug can cause ulcers. Amma was taking a low dose of anticoagulant ( ) and this, along with the NSAID was the most likely reason for her ulcer. Such a low dose combination would have perhaps not done any harm to a healthy adult, but a 81 year old lady is quite a different matter.

I was now reasonably confident what led to her internal bleeding. But interestingly, she most likely did not die of internal bleeding, even though her hemoglobin count was low – according to the doctor, that is quite unlikely to have caused such extreme atrial fibrillation, especially as she was clinically stable.

So, the following were clear:

First week of May 2020, she has a staph infection

Sometime in the second week of May 2020, the staph likely enters her blood, and started settling down in different parts of her body. This could have been the reason for her unusual shooting pains in her legs a few times.

The NSAID taken for the bacterial infection had, in combination with the anticoagulant, caused an ulcer that led to the beginning of slow internal bleeding perhaps starting as early as mid May. Starting second week of June, the internal bleeding perhaps increased leading to the dark brown stools that she mentioned in the last 5 days.

The ulcer also results in her strange deep hunger and craving for food, sometimes in the middle of night.

Sometime first week of June, the staph in her cervical bone starts giving her minor neck pain, something similar to osteomyelitis.

While all the above are surmises, they seemed to fit a pattern.

But the key question still remained unanswered: What resulted in the severe atrial fibrillation that killed her? None of the above had much chance of that.

I had once again hit a dead end.

It remained so until one day I was thinking about the deformed, discontinuous stent that was mentioned in her aortagram – CT scan of her aorta. I had assumed that the stent had been placed in her aorta during the first aortic surgery she had in 2011, which was an open heart surgery. However, something made me look up at videos of similar surgeries, and I suddenly realized something – they do not use stents in open heart surgeries. They had no need to, as they can well suture whatever they want to.

This was stunning. If she had no stent placed in her aorta during the open heart surgery, where did the deformed and discontinuous stent come from?

I kept thinking about it perhaps for an hour, and realized that there was only one possibility – that it was not a stent at all but something that looked like a stent to a radiologist.

That sounded very interesting, but also sounded very fictional. Unless…unless the staph bacterial could also settled down and form colonies in the sutures that had been laid down during the first surgery almost ten years back.

Was that possible? A bit of research showed that indeed was. Bacterial colonies were possible on sutures, and what is more, in some cases, these bacterial colonies form biofilms to protect them and grow all over the sutures, unharmed by even antibiotics owing to the biofilm.

This was exciting stuff. Is it possible that the staph, having entered the blood, settled in various places inside amma’s body, including on the sutures in her aorta and over a couple of weeks, had formed a zigzag colony inside a biofilm, which to a radiologist could have looked like a deformed discontinuous stent?

This was rarefied territory. There is little information available anywhere on this domain, and even a few cardiologists I spoke to were not very sure what I was talking about.

But to me, this is the only thing that fits the overall story.

Imagine the following scenario: Staph enters amma’s blood and forms a colony on the sutures inside the aorta and ensconced within the safety of biofilms. Over a period of time, antibodies are formed in her blood (remember, she had had this infection before, so there is a very high chance her body produced antibodies quickly). But the antibodies do not kill the staph in the aorta because of the biofilm and when a radiologist does a CT scan, she thinks the bacterial colony is a deformed stent (The CT scan done on amma was a low resolution one as she had a high amount of urea and creatinine in her blood at that time).

The antibody theory also explains another part of the puzzle: Why her hemoglobin level did not increase in spite of the blood transfusion. In many cases, presence of specific antibodies are known to reject the admission of newly transfused red blood cells.

I was almost there. All I now needed was an explanation of what the staph did. Here I can only surmise, but it is perhaps something like this: Something disturbed and destroyed the biofilm, perhaps the removal of anticoagulant, perhaps the infusion of new blood, or perhaps some antibacterials that the hospital gave. Once the biofilm was destroyed, the staph started doing mischief, perhaps they floated down into the heart through the aortic valve, or perhaps they formed blood clots which travelled into the heart through the aortic valve. If my hypothesis is correct, the colony of staph was large enough to do damage enough that directly or indirectly led to the atrial fibrillation.

So, this is how I think the events unfolded:

Amma has a bacterial infection in her foot and the medicines given for this results in her ulcer and internal bleeding. The bacteria this time enters her blood and settles down in many parts of her body including on the sutures in her aorta. Amma starts feeling weak and has symptoms owing to the internal bleeding. The hospital, in order to stop the internal bleeding, in addition to blood transfusion, stops her anticoagulants and prescribes a series of medications – all these in some way disturb the bacterial colony inside her aorta which directly or indirectly results in acute atrial fibrillation and death.

Is there any way I can prove any of the above? None. Is any doctor friend of mine convinced about the set of events described above? In parts perhaps, but not in entirety.

But given that no post mortem was done, and given her medical history and the symptoms of the final one month of her life, the above is the most likely, according to a non-medical guy like me.

I will be glad to interact with medical professionals on this.

Medical education <= Why did she die? => Side effects of medications

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Notes

176. It is possible that the chest pain decreased because she cut down a lot of her usual work and started sleeping a lot more in addition.

177, A fairly detailed list of symptoms for severe anemia caused by iron deficiency include: fatigue, shortness of breath, low blood pressure, leg cramps during a walk or exercise, fast or irregular heartbeat, pale skin, dizziness, strange cravings to eat items that aren’t food (dirt, ice, clay etc),  tongue swelling or soreness, cold hands and feet, swollen hands or feet, brittle nails and headaches. Amma presented only 4 of these – leg cramps, fatigue (well, it was more of a lot of sleep in her case), low blood pressure and a fast heartbeat.

178. This resulted in one of her 10 emergency hospitalizations.

…….

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