The spontaneous repatriation of Otto Warmbier was made on “humanitarian grounds”. The reason, as explained by the North Korean authorities, was illness caused by botulism. He returned to the US in a coma. Warmbier did not recover from this illness and since his death many questions have been asked. Notably how likely is it that Warmbier contracted botulism and did this really contribute to his death?
What is botulism?
Commonly, this occurs with tinned foods and indeed the name botulinum comes from the Latin word for sausage; botulus. Other ways of getting botulism can be through wound contamination, inhalation or inappropriate administration of cosmetic Botox (botulinum toxin) injections.
Botox is used in cosmetic procedures to prevent the release of a chemical known as acetylcholine. This acts as a messenger between nerves causing muscle contractions. Botulinum toxin inhibits the release of the neurotransmitter paralysing the muscle hence reducing the appearance of wrinkles.
At toxic levels all the muscles within the body become paralysed leading to respiratory failure. Interestingly, reduction in consciousness is not one of the signs of botulinum poisoning.
How did Otto Warmbier lose consciousness?
In the statement given by the North Korean officials, Warmbier is said to have taken a sleeping pill whilst unwell. This could be any number of medications used to help individuals with insomnia which include benzodiazepines, Z drugs, antihistamines and antidepressants. They all affect consciousness when taken in large amounts. Could an accidental overdose, therefore, be the cause of Warmbier’s death?
Taking sleeping tablets, also known as hypnotics, increase the risk of death three times more than the average population. However, within correctional institutions, this is not the most common cause of death. The majority of deaths within captivity occur as a result of suicide or homicide. North Korean correctional facilities are said to be brutal, with conditions for foreigners being no different. Curiously, doctors found no evidence of physical injury on examination of Warmbier’s body, however, CT scans confirmed extensive brain injury.
What else could explain Warmbier’s illness?
Another plausible diagnosis for Warmbier’s deterioration may be Guillian-Barre syndrome. This is an autoimmune condition which can be triggered by a preceding illness such as flu or diarrhoea. Like botulism, symptoms manifest with numbness, weakness and coordination problems mainly in the feet and hands also leading to respiratory failure if left untreated.
The decline of Otto Warmbier’s neurological status was rapid. This could be explained by a lack of oxygen to the brain as a result of respiratory failure. Once again, this is difficult to confirm. Aside from accidental poisoning with sleeping tablets, another cause of death could include a stroke.
Warmbier was perhaps too young to have had a stroke but given the difficult conditions he was under, he may well have developed a psychiatric illness. This is common among detainees around the world. Indeed manifestations of poor mental health, such as depression, have been shown to precede strokes. Strokes very rarely, however, contribute to complete loss of consciousness. Such a phenomenon is usually seen with bleeds on the brain known as subarachnoid haemorrhages or haemorrhagic strokes. CT scans, performed in the US, showed no evidence of bleeds on Warmbier’s brain.
The hardest piece of evidence in this case is the CT imaging, which shows extensive brain injury. This matches the severe deterioration of Warmbier’s neurological state. Yet with no story to explain the CT findings and no evidence of injury to the body, it is very difficult to establish a robust cause of death. In addition to this, negative stool tests for botulism suggest that it is not likely to be a contributing factor. Caution must be exercised, however. Medical tests sometimes need to be repeated to ensure accuracy. As Warmbier’s parents have refused an autopsy it will be difficult to amass further evidence to explain his death. The case will forever be shrouded in speculation and mystery just like the state in which these incidents occur.
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Any opinions above are the author’s alone and may not represent those of his/her affiliations. Any comment is based on the best available evidence at the time of writing. All data is based on externally validated studies unless expressed otherwise. Novel data is representative of the sample surveyed. An online recommendation is no substitute for seeing your own doctor and should not be taken as medical advice. Article edited for publication by Dr Hannah Arnstein
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Sources and Further Reading
- http://www.standard.co.uk/news/world/who-is-otto-warmbier-why-did-north-korea-imprison-him-how-did-he-die-all-we-know-on-late-american-a3568871.html (Article from The Standard about Otto Warmbier)
- https://www.cia.gov/library/publications/the-world-factbook/geos/kn.html (CIA fact file on North Korea)
- http://www.mayoclinic.org/diseases-conditions/botulism/basics/definition/con-20025875 (Mayo Clinic Article on botulism)
- https://www.gov.uk/government/publications/botulism-confirmed-cases (Government ebpage on incidence of botulism in the UK)
- http://www.who.int/csr/delibepidemics/clostridiumbotulism.pdf (WHO document on clostridium botulinum)
- http://www.webmd.boots.com/a-to-z-guides/botox-medical-uses (WebMD page on botox)
- https://www.britannica.com/science/acetylcholine (Britannica article on acetylcholine)
- http://www.bris.ac.uk/synaptic/basics/basics-4.html (Bristol University web page on acetylcholine)
- https://patient.info/doctor/respiratory-failure (Patient.co.uk article on respiratory failure)
- http://www.mayoclinic.org/diseases-conditions/guillain-barre-syndrome/basics/definition/con-20025832 (Mayo clinic article on Guillian Barre syndrome)
- https://medlineplus.gov/autoimmunediseases.html (Medline plus webpage on autoimmune diseases)
- http://www.webmd.boots.com/sleep-disorders/guide/insomnia (WebMD webpage on insomnia)
- https://www.mind.org.uk/information-support/drugs-and-treatments/sleeping-pills-and-minor-tranquillisers/about-benzodiazepines/#.WVvNnojytPY (MIND webpage on benzodiazepines)
- https://patient.info/health/benzodiazepines-and-z-drugs (patient.co.uk article on benzodiazepines Z drugs)
- http://www.nhs.uk/conditions/Antihistamines/Pages/Introduction.aspx (NHS webpage on antihistamines)
- https://mind.org.uk/information-support/drugs-and-treatments/antidepressants/#.WVvOWojytPY (Webpage from the mental health charity MIND on antidepressants)
- https://www.britannica.com/topic/sedative-hypnotic-drug (Britcannica article on hynotic drugs)
- http://bmjopen.bmj.com/content/2/1/e000850 (Paper on hypnotics and risk of death)
- https://academic.oup.com/aje/article/173/5/479/90274/Prisoner-Survival-Inside-and-Outside-of-the (Paper on causes of death in correctional facilities)
- http://www.independent.co.uk/news/world/asia/dprk-north-korea-south-prison-camp-guard-reveals-what-life-like-punishment-execution-a7710696.html (Article from the Independent on North Korean Prisons)
- http://www.telegraph.co.uk/news/2016/04/25/what-happens-to-foreigners-arrested-in-north-korea/ (Article from the Telegraph on detained foreigners in North Korea)
- https://trustedmedicine.net/2017/06/08/14-year-old-recognises-stroke-in-mother-after-recalling-school-lesson/ (Trusted Medicine article on stroke)
- http://www.hopkinsmedicine.org/healthlibrary/conditions/nervous_system_disorders/neurological_examination_85,P00780/ (Webpage from JohnsHopkins University on the constituents of a neurological examination)
- http://bjp.rcpsych.org/content/200/5/364.short (Paper on mental health in prisoners around the world)
- http://journals.lww.com/psychosomaticmedicine/Abstract/2000/07000/Symptoms_of_Depression_as_a_Prospective_Risk.1.aspx (Paper on depression as a predictive risk factor for stroke)
- http://emedicine.medscape.com/article/1164341-overview (Medscape webpage on subarachnoid haemorrhage)
- http://www.mayoclinic.org/diseases-conditions/stroke/symptoms-causes/dxc-20117265 (Article on strokes from Mayo Clinic)