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ss nucleus - summer 1998,  Differential Diagnosis 24

Differential Diagnosis 24

2 Kings 1:2. Ahaziah fell through the lattice of his upper room and injured himself. He subsequently died. But if you had to write the death certificate what would you enter as part Ia?

The Hebrew word translated in the NIV as 'injured' gives us no clues as elsewhere in scripture it is used in a very non-specific way (see Judges 16:7, 1 Samuel 19:14, 1 Kings 14:5, Psalm 35:13). However, we do know that falling from a height most often leads to traumatic injury of the head, internal organs or bones.

A traumatic head injury can result in intracerebral contusion or sub-dural haematoma. Neurological signs can be absent initially until the haemotoma grows to a sufficient size to cause compression of the brainstem. However, Ahaziah shows none of the intermittent confusion and deteriorating level of consciousness that is typical with this kind of injury. His conversations with the messengers and with Elijah are coherent and his death occurs suddenly.

Injury to internal organs is also unlikely since a ruptured liver, spleen or gut quickly leads to hypovolaemic shock and death.

Most probably Ahaziah suffered a fracture of one or more of his long bones. This is supported by the evidence that he was confined to bed (v16). But why would a fracture kill Ahaziah after what appears to be a period of several days? A compound fracture can become infected but none of the features of such a complication are given. Ahaziah appears to have died suddenly once Elijah had pronounced judgement on him for consulting foreign gods and lacking faith in the God of Israel (v.16-17).

The most likely explanation is a fatal pulmonary embolism. Confined to bed following his fracture Ahaziah was at a high risk of suffering from this dreaded complication. Signs of deep vein thrombosis can be absent and if the embolus is large death occurs instantly. If you ever get called to a cardiac-arrest on the orthopaedic ward it should be one of the first differentials to go through your mind.

Differential Diagnosis 25

Upon hearing of his narrow escape from the wrath of David, Nabal's heart failed 'and he became like a stone'. About ten days later he died. (1 Samuel 25:37-38). From the details given about Nabal's pre-morbid personality and lifestyle can you suggest the most likely cause of death?

Luke's opinion in the next issue.

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