I, MICHAEL D. INNIS,. declare as follows:
1. I am not a party to this action. I am competent to testify
as a witness as set forth herein.
2. I am a physician licensed to practice medicine in Australia and
in the United Kingdom. I am a pathologist and a hematologist. My qualifications
are MBBS (Bachelor of Medicine) University of Madras 1942; DTM&H (Diploma
of Tropical Medicine) University of Liverpool; FRCPA (Fellow
of the Royal College of Pathologists) 1960 (Australia);
FRCPath (Fellow of the Royal College of Pathologists) 1972 (United Kingdom).
I have substantial experience in
hematology and have had experience in interpreting laboratory results
for over 30 years. I have been a part time lecturer
in Medicine at the University of Queensland and have instructed candidates
appearing for Fellowship of the Royal College
of Pathologists of Australasia.
3. Some of my published medical articles and letters include:
(1) Simian virus 40 contaminated polio vaccine and cancer rates.
JAMA. (Nov 4, 1998) 280(17):1481-2;
(2) Clinical problem solving--the role of expert laboratory systems. Med
Inform (Lond). (Jul-Sep 1997) 22(3):251-61;
(3) Computerized interpretive reporting in haematology. Med J Aust. (Jan
2, 1989) 150(1):49;
(4) Bain BJ, Neill PJ, Scott D, Scott TJ, Innis MD, Automated differential
leucocyte counters: an evaluation of the Hemalog
D and A comparison with the Hematrak. I. Principles of operation; reproducibility
and accuracy on normal blood samples. Pathology (Jan.1980) 12(1):83-100;
(5) Letter: Transmission of infectious mononucleosis by blood aerosol?
Lancet. (Jun 5 1976) 1(7971):1249;
(6) Letter: Nephroblastoma--genetic aspects. Med J Aust. (Aug 17 1974)
2(7):268;
(7) Epidemiology of childhood leukaemia in migrant populations. Med J
Aust. (Aug 3 1974) 2(5):155-8;
(8) Hereditary theory of childhood oncogenesis. Oncology. (1972) 26(5):474-80;
(9) Nephroblastoma: possible index cancer of childhood. Med J Aust. (Jan
1 1972) 1(1):18-20; (9) Hartley LC, Morgan
TO, Innis MD, Clunie GJ. Splenectomy for anaemia in patients on regular
haemodialysis. Lancet. (Dec 18 1971) 2(7738):1343-5;
(10) Murphy KJ, Innis MD, Hepatic disorder and severe bleeding diathesis
following nitrofurantoin ingestion. JAMA. (Apr
29 1968) 204(5):396-7.
4. In September 2003, I was asked to review the records of Alexa Davidson
DOB 11/21/01 who died on 1/21/02 with an Autopsy diagnosis of Multiple blunt
force injury.
5. I have reviewed all the records which were sent to me.
6. I do not know the petitioner or anyone in the Davidson family.
I have received no compensation whatsoever to review
the records and have done so on a pro bono basis.
7. Upon reviewing these records, it is my opinion that Alexa's problems
resulted from a defect of hemostasis (blood clotting mechanism) and superimposed
Hypoxia (lack of oxygen) causing Intracerebral pathological changes following
an Apparent
Life Threatening Event brought on by her illness.
I base this opinion on the evidence as recorded below.
Revised Report on Alexa Davidson
Date of birth 21st November 2001 Deceased 22nd January 2002
Alexa was born after a 40 week gestation by normal vaginal delivery. Her
APGAR scores were 9 at 5minutes and 9 at 10 minutes. She was given Hep B
and Vitamin K by IM injection shortly after birth. Pustular Melanosis was
observed at birth
but cleared in a few days.
The newborn screen tests were negative.
When seen at a 2 week well check no significant abnormality was found.
At this appointment she was being breast fed. How long breast feeding was
continued and whether it was supplemented with any Vitamin preparations is
not recorded in the information sent to me.
Comment
This information is important because at this age children are vulnerable
to deficiencies in Vitamins C, K and D as well as chemicals such as Calcium
and Phosphorus, all of which are associated with rib and skeletal fractures,
and with bleeding in
some instances.
--------------------------------------------
On the 18th of December 2001 Alexa was taken to the doctor because of
blood in her stool and "bruising". She was also
said to be crying more than usual over the last 3 or 4 days.
A blood test was done which importantly showed:
1. Hemoglobin level 14.6 gm/dl Normal Range 14.0 - 22.0
2. Lymphocytes 13.26 x 10x3ul 1.25 - 7.0
3. Platelets 253 x 10x3ul 150 - 400
Comment
At this stage blood tests specifically designed to determine the cause
of bruising and bleeding (PT, APTT, Fibrinogen and
FDP) should have been done but I have not seen the results of those test
if they were done.
The possibility of both Vitamin C and K deficiency would need to be consider
as both are capable of causing "fractures" as
well as bruising and bleeding from the gut, and both may have a nutritional
origin. But no tests for these conditions were done.
However there is a significant abnormality in the Lymphocyte count which
is approximately double the upper value of normal and should alert one to
the possibility of a viral infection especially, at this age, the Epstein-Barr
virus which would account
for the infant's distress.
--------------------------------------------------
Alexa was crying, vomiting and off her feeds on January 20th and her mother
took her to the Blanchfield Memorial Hospital
at about midnight. A chest X-Ray was taken and blood was taken for testing.
The mother was advised to give the infant medication when she arrived home,
which she did.
Alexa was handed over to the father who changed the baby's diaper and
noticed the child had difficulty in breathing. He immediately sought the
help of the mother and they rang 911 for assistance.
An ambulance arrived at 5.23 and Alexa was taken to Gateway Medical Center
where the admission note states the child
was found by the parents to be breathless and blue about the face and had
been wheezing prior to the respiratory arrest.
Comment
The sudden difficulty in breathing followed by respiratory arrest, cyanosis,
limpness and unresponsiveness which were all recorded in this child is given
the name of "Apparent Life Threatening Event" (ALTE).[1]
Infant apnea, more appropriately called an apparent life-threatening event
(ALTE), was defined by the 1986 National
Institutes of Heath Consensus Development Conference on Infantile Apnea
and Home Monitoring as follows:
An episode that is frightening to the observer and is characterized by
some combination of apnea (central or occasionally obstructive), color change
(usually cyanotic or pallid but occasionally erythematous or plethoric), marked
change in muscle
tone (usually marked limpness), choking or gagging. In some cases, the observer
fears that the infant has died.
Alexa stopped breathing for several minutes before being intubated and,
as has been pointed out by Geddes et al;,
intracerebral hemorrhages may result [2].
-------------------------------------------------
When admitted to Gateway Medical Center some blood tests were done of
which the most significant were:
1. Blood pH 7.19 Normal Range 7.35 - 7.45
2. Hemoglobin 6.8 g/dL 12.2 - 16.2
3. Lymphocytes 69.6 % 20.0 - 50
4. Neutrophils 22.3 % 37 - 80
Comment
"Severe metabolic acidosis with inadequate resp. comp" was the comment
of the Pathologist and I agree entirely that is the explanation of the Blood
pH reading.
Metabolic acidosis is the result of the body, including the brain, being
deprived of Oxygen. When the brain is deprived of Oxygen it swells causing
cerebral edema and subdural hemorrhages.[2]
The other significant abnormality is the marked increase in lymphocytes
associated with a reduction of neutrophils. After
more than 30 years of reading and reporting blood tests this combination
suggests an infection with the Epstein-Barr Virus (EBV).
The EBVirus causes Hepatitis which in turn causes a loss of the proteins
necessary for the coagulation of blood. One result
is Vitamin K Deficiency Bleeding (VKDB) a well known complication of defective
liver function, which would explain the fractures, bleeding and bruising
seen in the child.
-----------------------------------------------------------
The postmortem findings have been summarized
Patterned contusions on the forehead and right arm.
Bilateral subgaleal hemorrhages
Linear fracture of left occipital bone with dilated suture lines of the
skull
Subdural and subarachnoid hemorrhage, bilateral.
Severe cerebral edema with dilated ventricles.
Acute hemorrhage around right and left optic nerves
Recent and old rib fractures.
What has not been included in this summary is the fact that an enlarged
lymph node was found in the neck.
Organ donation - heart surgically removed.
Comment
Each and every one of the above postmortem findings has a Natural explanation.
It has been shown that Alexa displayed symptoms of bleeding in that she
had blood in her stool and was bruising.
In support of the contention that a diagnosis of EB Virus infection is
valid, is the finding of "one slightly enlarged soft,
movable lymph node in the neck" which the Pathologist does not include in
his summary of postmortem findings.
This finding is exactly what one would expect in EBV infection and has
to my knowledge never been put forward as a sign
of "multiple blunt force injury."
Having contributed to the medical literature on this subject (Letter Lancet
Jun 5 1978) I am confident with a reasonable
degree of medical certainty that Infectious Mononucleosis from EBV infection
was a factor in Alexa's demise.
Finally, regarding the question of subdural and intracerebral hemorrhages,
Geddes et al state:
"our observations indicate that in the immature brain, hypoxia both alone
and in combination with infection is sufficient to
activate the pathophysiological cascade which culminates in altered vascular
permeability and extravasation of blood within
and under the dura." [2].
And there is abundant evidence of Cardio-Respiratory Arrest and Hypoxia
in this child's history.
CONCLUSION
Alexa was ill prior to the fatal episode of Cerebral hemorrhage. She had
both clinical and laboratory evidence of infection
with the Epstein-Barr virus which led to dysfunction of her liver causing
an abnormality of the blood clotting process and subsequent bruising and the
so-called "fractures". I have pointed out in the British Medical Journal what
Radiologists and
some Pathologists call "fractures" are in fact healing subperiosteal (the
fibrous sheath covering bone) hemorrhages.[3 ]. No
one has challenged my view.
The subdural hemorrhage and other intracranial lesions are explained by
the work of Geddes et al; who has shown them to
be evidence of Anoxia (lack of oxygen).
The father has given a clear description of the Apparent Life Threatening
Event Alexa suffered which caused the Cardio-Respiratory arrest, Anoxia and
its fatal consequences.
The cause of death was, with a reasonable degree of medical certainty,
a defect of hemostasis (blood clotting mechanism)
and superimposed Hypoxia (lack of oxygen) causing Intracerebral pathological
changes following an Apparent Life
Threatening Event brought on by a pre-existing illness of EB Virus Infection,
I certify that I have presented the truth and have not knowingly presented
any statement that is false.
Finally, since I believe EB Virus infection played a significant role
in Alexa's death I have concerns that the donation of her
heart may cause problems in the recipient.
Michael D. Innis MBBS; DTM&H; FRCPA; FRCPath
Honorary Consultant Haematologist
Princess Alexandra Hospital
Brisbane.
Australia.
Reference:
1. Author: Brent R King, MD, Chair, Associate Professor, Department of
Emergency Medicine, The University of Texas at Houston Medical School
Brent R King, MD, is a member of the following medical societies: American
Academy of Emergency Medicine, American Academy of Pediatrics, American College
of Emergency Physicians, and American College of Physician Executives
Geddes JF, Tasker RC, Hackshaw CD, Nickols CD et al. Dural haemorrhage
in non traumatic infant deaths: does it explain
the bleeding in "Shaken Baby Syndrome". Neuropathology and Applied Neurobiology
2003 (29) 14 - 22
Innis MD. Misdiagnosis of SBS
RAPID RESPONSES:
Michael D Innis
Misdiagnosis of SBS
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