'No proper medical advice for Kumaramangalam for three months'

The following is the report of a six- member Government appointed Committee, which probed the death of the Union Minister, P. R. Kumaramangalam:

Late Shri Kumaramangalam was admitted to Apollo Hospital, New Delhi, on 14-4-2000 with complaints of fever. As per case records, the fever had been present for the previous two weeks. During the stay in the hospital he was extensively and aggressively investigated on two counts:

1. Malaria infection specially due to P. falciparum as he had visited Andaman & Nicobar Islands in the last week of March, 2000. It was conclusively excluded, but treated empirically. This practice is not unusual in India.

2. In view of a history of heavy cigarette smoking by Shri Kumaramangalam, the pneumonic patch in the right middle lobe was investigated to rule out bronchogenic malignancy. The possibility of malignancy, tuberculosis and fungal infection was ruled out by various investigations including bronchoscopy and fine needle aspiration cytology (FNAC) of the lung (under CT guidance) as well as PCR for Myco. tuberculosis. However, a precise cause of the pneumonic patch could not be established.

He was put on antimicrobials as detailed below: Azithromycin 14th to 18th April (5 days); Ceftriaxone 14th to 16th April (3 days); Imipenem 17th to 20th April (3 days); Syscan (fluconazole) 21st to 23rd April + OPD for 3 days; Metakelfin 3 tablets/single dose/18th; Falcigo (Artesunate) 20th to 23rd April + OPD (2 days).

The specimens obtained on the 21st of April during CT-guided FNAC of the pneumonic patch revealed (a) sheets of polymorphonuclear leucocytes with macrophages, consistent with an abscess in three slides and (b) mainly macrophages with lymphocytes in the other slide. At the time of FNAC, antibiotics had been ceased on the request of the patient.

Haemoglobin, total leukocyte count and differential count were done on three different occasions.

14-4-2000 WBC 6000 Lymphocytes 40% Neutrophilis 49%; 20-4-2000 WBC 4400 Lymphocytes 55% Neutrophilis 39%; 21-4-2000 WBC 5000 Lymphocytes 56% Neutrophilis 41%.

On all three occasions, the tests revealed an inappropriately low total WBC count considering the two sites of infection and a relative lymphocytosis and raised ESR.

There is no mention about the morphological characteristic of leukocytes in any of the reports. Dr. Sangita Rawat, Consultant Pathologist, during her appearance before the committee, emphatically mentioned that there were no abnormal cells on the peripheral smear. Abnormal cells were also not present in the peripheral blood smears done later at AIIMS.

The findings of TLC, DLC, raised ESR and FNAC are evidence of an inadequate polymorphonuclear leucocyte response to sepsis by the bone marrow. A consultation with clinical Haematologist was warranted to evaluate the immuno-haematological status of the patient. The treating doctor, Dr. P. Rao, had also considered evaluation of immune status in view of the pneumonic patch and urinary tract infection by resistant E coli infection, but this line of investigation was not pursued further.

Whether a bone marrow aspiration and/ or other investigations were indicated during his initial hospitalisation for fever is debatable. In retrospect, if the aforementioned investigation had been carried out, it may have helped to arrive at a definite diagnosis. Even if subsequent developments are not taken into account, the physician should have informed the patient that the blood counts were a bit unusual and should definitely be repeated in two to three weeks time after discharge.

There is no evidence of follow-up by his treating physician after the discharge from Apollo Hospital on 23-4-2000, though the late Shri Kumaramangalam had gone there on 8-5-2000 for a Chest X-Ray and blood count test. This was done on the orders from the Chairman's office without clinical request by the doctor. While X-Ray Chest showed improvement, the peripheral blood count still showed a lymphocytosis of 58%. There was no clinical evaluation at this visit, since the Minister failed to keep the scheduled appointment with Dr. P. Rao.

Shri Kumaramangalam continued to lose weight steadily and lost about 10 kgs., he also complained of tiredness and inability to cope with the schedule he was used to earlier. According to family members, no doctor was consulted officially and no investigation done during the period from 8-5-2000 till his admission to AIIMS on 13-8-2000. However, he was taking anti- tubercular drugs on the advice of doctors, well-wishers and friends without improvement.

It is important to point out that no prescriptions were made available, and neither the dose or frequency of the drugs administered could be ascertained. Mrs. Kumaramangalam, on being asked, stated that two doctors, one being her father and the other a Dr. Tyagi, suggested that he should take anti-tubercular medication. Further, according to her, the ``opinion of Dr. Tyagi mattered much''.

It may be pertinent to mention here that late Shri Kumaramangalam used to take tablet Wysolone 10 mg occasionally and this is recorded in the case sheet of AIIMS. This was confirmed by the statement of Mrs. Kumaramangalam who said he used to take the drug, ``for body ache and exhaustion, though he was not addicted to it''.

Since discharge from Apollo Hospital, he visited the U.K. and Tamil Nadu and whether he had consultation with any doctor is not known and the same is denied by the private secretary and family members.

The Committee reviewed the records provided by AIIMS, including, all the peripheral blood smears, bone marrow aspirates and trephine biopsies from 14-8-2000 to 22-8-2000. The peripheral smear showed leucopenia with severe toxic change in the polymorphs. The bone marrow aspirate of 17-8-2000 showed a significant increase in atypical lymphocytes which is suggestive of a Non-Hodgkin's Lymphoma. The history of irregular fever, weight loss, episodes of sepsis, leucopenia, focal hypodense lesions in the spleen (on CT) and atypical lymphocytes in the bone marrow are consistent with Non-Hodgkins Lymphoma. However, cytochemical stains and immunophentyping are necessary to confirm this diagnosis.

``Overall the committee feels that the most significant contribution towards the final outcome in the case of Shri Kumaramagalam was the fact that the patient did not receive appropriate medical advice for over three months following his discharge from Apollo Hospital till his final admission at AIIMS.''

- Signed: (Lt. Gen (Retd.) D. Raghunath, M.D.), Former D.G. - AFMS (Bangalore); (Dr. K. R. Sethuraman, M.D.), Prof. of Medicine, JIPMER, Pondicherry; (Dr. Mammen Chandy), HOD, Haematology, Christian Medical College, Vellore; (Dr. E. Chandrasekaran, M.D.); Consultant in Medicine, Dr. RML Hospital, New Delhi; (Dr. P. S. Gupta), Sr. Consultant in Medicine, Sir Ganga Ram Hospital, New Delhi; (Dr. C. P. Singh), M.D. (Medicine) & M.D. (Chest), Medical Superintedent, Dr. RML Hospital, New Delhi.

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