A case of toxic blood
Philadelphia, Pennsylvania, United States
The Dancing Mania by Hendrick Hondius (1642). Wellcome Collection. CC BY 4.0.
On a blustery winter day, a molecule of water condenses around a particle of dust in the air. The structure grows in size as it falls closer to earth, and before it hits the ground outside, it has crystallized into a perfect, six-sided snowflake. Miles away, a thirty-one-year-old woman is rushed to an emergency room in Riverside, California. Unbeknownst to her, a similar process is unfolding in her blood. Mysterious crystals have precipitated within her vessels, a place where—all else being normal—crystals should not be. The story grows even stranger: the first nurse to see the patient in the emergency room collapses a few moments after handling her blood. Before anyone could question why a seasoned nurse had fainted at the sight of blood, two more medical personnel also grow lightheaded and collapse. By the end of the evening, the patient is pronounced dead and twenty-three previously healthy hospital staff members are suffering from symptoms of a strange, unidentified illness.1 Physicians, police officers, and investigators are utterly bewildered: what on earth is going on?
The details are well-documented: around 8:15 PM on February 19, 1994, a woman named Gloria Ramirez was brought to the emergency room at Riverside General Hospital. She was awake but incoherent, with a rapidly bottoming blood pressure and frenetic pulse. It was quickly revealed that Ms. Ramirez had been battling advanced cervical carcinoma for months. A whole host of medication was administered to stabilize her heartbeat and blood pressure, but to no avail. Eventually, the decision was made to defibrillate her. As emergency room staff removed her shirt to apply voltage to her chest, they noticed the first strange observance of the evening: Ms. Ramirez’ body was covered in a greasy sheen, and her breath smelled like fruits and garlic.1,2 Strange, but not altogether alarming. Perhaps she had been receiving an oil massage after enjoying a dish that was both savory and sweet.
As doctors surrounded Ms. Ramirez to stabilize her acute symptoms, a registered nurse named Susan Kane began to draw blood for a routine panel of blood chemistries. Here was the second strange observance of the night: Ms. Ramirez’ blood had the distinct smell of ammonia. What is more, when the blood in the vial was swirled around, a wash of straw-colored crystals swirled around within it.1–3 The ammonia scent could perhaps be explained away. Ms. Ramirez had advanced cervical cancer and might have been receiving a slew of chemotherapeutic drugs, some of which can lend the blood a foul odor (though, it was revealed later that Ms. Ramirez was not, in fact, receiving chemotherapy at all).4 But what were crystals doing in blood? Susan Kane passed the vial for Julie Gorchynski, a medical resident, and Humberto Ochoa, the attending physician in charge of the emergency room, to examine. Dr. Gorchynski and Dr. Ochoa agreed—this was strange indeed.
Neither, however, had a chance to ruminate for very long. Within a few minutes, Susan Kane had fainted on the scene. Not long after, Dr. Gorchynski began to feel lightheaded. She sat for a few moments before fainting as well. The third to fall was Maureen Welch, a respiratory therapist who had spent time at Ms. Ramirez’ bedside, trying to pump oxygen into her lungs. Rapidly, things got worse. Dr. Gorchynski was convulsing and lapsing in and out of apnea. Nearby, Welch was experiencing the strange sensation that she could not move her limbs. Immediately, the emergency room was evacuated to the outside parking lot, where more and more staff members were beginning to feel lightheaded and nauseated. Dr. Ochoa stayed in the hospital with a small team to continue resuscitation efforts.2
Less than one hour after Ms. Ramirez arrived at the hospital, she was pronounced dead. Outside, twenty-three hospital employees were ill and five were eventually hospitalized. Dr. Gorchynski was admitted to the intensive care unit for two weeks, where she developed hepatitis, pancreatitis, and avascular necrosis in her knee.2,5 However, when the coroner’s report finally came back for Gloria Ramirez two months later, no toxic compound or metabolite was reported. The cause of death was declared to be cardiac arrhythmia due to kidney failure, related only to her cervical cancer.6
Though the coroner had closed the investigation on Ms. Ramirez’ death, citing the strange smells as simply the “residues of a dying person,”6 the circumstances surrounding her death remained far too bizarre to shut the door on speculation altogether. Because thorough investigation from forensic experts yielded no indication of any underlying toxin, initial theories centered around models of mass hysteria. Documented cases of mass hysteria date back to the Middle Ages. The Dancing Plague of 1518 caused nearly 400 townspeople in Strasbourg, Alsace, to dance and writhe for days without rest, until they succumbed to death from heart attack or exhaustion.7 Outbreaks of mass hysteria have been documented across the globe more recently as well. In November 2012, nearly two thousand students across fifteen schools in Sri Lanka were treated for rashes, vomiting, vertigo, and cough; however, subsequent medical investigation showed no underlying illness or distinct cause, and investigators concluded that the cause was likely psychogenic.8 The most common symptoms experienced in mass hysteria are nausea, vomiting, headache, and lightheadedness, which are all in line with symptoms experienced by hospital workers at Riverside General.9 Furthermore, none of the ambulance workers who were in contact with Ms. Ramirez that evening showed any signs of the mysterious illness, perhaps because they were no longer at the scene when the first people had started fainting.2
Many, like Dr. Gorchynski, who spent weeks in the intensive care unit recovering from the incident, were unwilling to accept mass hysteria as a mechanism by which many highly-trained medical personnel would succumb to bouts of syncope and convulsions. After all, doctors and nurses in the emergency room deal with gruesome traumas on a daily, if not hourly, basis. Dr. Gorchynski and others pushed for further investigations to be conducted by Livermore National, an independent laboratory in San Francisco. Livermore posited a novel, highly outlandish, yet somehow believable theory.
Dimethyl sulfoxide, also called DMSO, is a powerful solvent with a diverse range of uses, from stripping paint off of wooden doors to cryoprotection of cells growing in culture. In its gel form, it is also used as a home remedy by athletes and the elderly to ease muscle aches. Users of DMSO gel often report a garlicky taste in their mouths, a detail which rang familiar to the investigators at Livermore. DMSO is relatively harmless, but is just one oxygen atom short of dimethyl sulfone, or DMSO2. Interestingly, as Livermore scientist Patrick Grant studied the compound further, he found that when a blood analogue was loaded with DMSO2 and cooled to around seventy degrees, which is just about how cold the emergency room at Riverside General was, it precipitated crystals.5
DMSO2 is also a harmless compound; however, it is two oxygen atoms short of dimethyl sulfate, or DMSO4. Unlike DMSO or DMSO2, DMSO4 is a truly vicious substance whose vapors can cause necrosis of tissue, convulsions, delirium, cardiotoxicity, kidney failure, and even death.
So how plausible is this proposed journey from dimethyl sulfoxide to dimethyl sulfone to dimethyl sulfate? Depending on who you ask, the answers might range from pretty unlikely to downright impossible. Pretty unlikely, however, still leaves a sliver of possibility that things had aligned in exactly the right way to create this perfect storm. A high concentration of oxygen can push DMSO to DMSO2, and Ms. Ramirez did receive pure oxygen through a mask when she was in the ambulance. Because DMSO2 is still harmless, it would follow that at this point in the reaction, there was no toxic metabolite in Ms. Ramirez’ blood, explaining why the paramedics in the ambulance were spared.
Here is where the theory gets tricky. It is not very easy to get from DMSO2 to DMSO4. The electric shocks later delivered to Ms. Ramirez could have facilitated the conversion from DMSO2 to DMSO4, but the mechanism by which that might happen is entirely theoretical and has yet to be reproduced.3,5 The DMSO theory holds some water, but can be quite easily emptied of it. What is more—when questioned, Ms. Ramirez’ family staunchly denied that she ever even used DMSO at all.
Other theories have been proposed, though none are any more convincing. In 1997, the now-defunct newspaper The New Times LA built a theory on the fact that Ms. Ramirez’ blood bore the smell of ammonia and methamphetamine precursors are known to smell like ammonia. This, in conjunction with the fact that Riverside County is one of the largest narcotic distribution points in the country, led The New Times to posit that hospital employees were smuggling methamphetamine precursors in IV bags, and mistakenly administered one to Ms. Ramirez.3,10 While this would explain the symptoms Ms. Ramirez was experiencing, and perhaps even the symptoms of the hospital personnel, the coroner’s report was clear in that no toxins—methamphetamine or otherwise—were found in Ms. Ramirez’ blood.
Unfortunately, there is no definitive conclusion to Gloria Ramirez’ story. It is possible that the electric charge of the defibrillator converted DMSO2 to DMSO4 in her blood. It is just as possible that this was a case of mass hysteria sparked by two ill-timed bouts of lightheadedness. It is possible that both these things happened, and it is possible that neither did. Until another explanation arises, all we have are these theories, the smell of garlic, and a wash of straw-colored crystals in a vial of blood.
- The Toxic Lady. Skeptoid. https://skeptoid.com/episodes/4291. Accessed January 14, 2020.
- Analysis of a Toxic Death. Discover Magazine. https://www.discovermagazine.com/health/analysis-of-a-toxic-death. Accessed January 14, 2020.
- What’s the story on the “toxic lady”? The Straight Dope. https://www.straightdope.com/columns/read/999/whats-the-story-on-the-toxic-lady/. Published March 22, 1996. Accessed January 14, 2020.
- After Airtight Autopsy, Mystery Lingers in Case of Hospital Fumes – The New York Times. https://www.nytimes.com/1994/02/26/us/after-airtight-autopsy-mystery-lingers-in-case-of-hospital-fumes.html. Accessed January 14, 2020.
- Grant PM, Haas J, Whipple RE, Andresen B. A possible chemical explanation for the events associated with the death of Gloria Ramirez at Riverside General Hospital. Forensic Sci Int. 1997;87(3):219-237. doi:10.1016/S0379-0738(97)00076-5
- Coroner Says Body Probably Emitted Fumes. Los Angeles Times. https://www.latimes.com/archives/la-xpm-1994-04-30-mn-52166-story.html. Published April 30, 1994. Accessed January 14, 2020.
- “Dancing Plague” and Other Odd Afflictions Explained : Discovery News. https://web.archive.org/web/20121013075434/http://dsc.discovery.com/news/2008/08/01/dancing-death-mystery.html. Published October 13, 2012. Accessed January 14, 2020.
- News L-N com SLU. Sri Lanka:Mass Hysteria cause of School Student Allergy. https://www.lankauniversity-news.com/2012/11/sri-lankamass-hysteria-cause-of-school.html. Accessed January 14, 2020.
- Pastel RH. Collective behaviors: mass panic and outbreaks of multiple unexplained symptoms. Mil Med. 2001;166(12 Suppl):44-46.
- How Riverside County became America’s drug pipeline. Desert Sun. https://www.desertsun.com/story/news/crime_courts/2015/11/11/riverside-county-drug-trafficking/75232146/. Accessed January 14, 2020.
SHRUTHI DEIVASIGAMANI graduated from Princeton University, where she studied neuroscience and creative writing. She is interested in the role writing plays for both medical and non-medical readers. She is currently a second-year medical student at Sidney Kimmel Medical College at Jefferson University.
Submitted for the 2019–2020 Blood Writing Contest & Highlighted in Frontispiece Volume 12, Issue 2 – Spring 2020