On Aug. 25, the Pennsylvania Department of Health reported 393 measles cases and two associated deaths from an outbreak that centered on Lancaster County. One death was in a newborn infant. Within a couple of days, HHS Secretary Robert F. Kennedy Jr. said the deaths may have been fabricated. This wasn't surprising. Just a year ago, when two little girls in West Texas died from measles, anti-vaccine activists -- who don't want us to believe that their anti-vaccine advocacy is killing children -- also claimed that poor medical care, not measles, had caused the deaths.
This time it's different. Anti-vaccine activists' claims were supported by a Lancaster County coroner named Stephen Diamantoni, MD, a board-certified family medicine practitioner, who said that measles was not the cause of the newborn's death. Diamantoni said that he had detected "measles virus in the infant's lung tissue," and that the baby had died from an internal hemorrhage and "traumatic rupture" of the spleen. Because measles virus can cause enlargement of the spleen and thinning of the splenic capsule, it is plausible that the child's splenic rupture occurred during the birth process, which can be traumatic. Nonetheless, the coroner stated that because "there was no swelling or enlargement [of the spleen] whatsoever," that he does not consider measles to be the cause of death.
Diamantoni is in a tough spot. Splenic ruptures are extremely rare in neonates. He is dealing with an unusual case. So, it's easy to understand his caution in assigning a cause. However, it's hard to make sense of what he is saying.
First, Diamantoni put a lot of emphasis on his finding of a normal-sized spleen, emphasizing it with the word "whatsoever." To him, this meant that measles virus didn't affect the spleen so it couldn't be the cause of death. However, once a spleen is ruptured, it's difficult to tell whether it was enlarged. For example, if you find a balloon on the ground that has burst, it's hard to know how big it was before it burst.
Second, Diamantoni might have found that the spleen was vulnerable because the child had suffered from something other than measles that had caused splenic fragility before birth; specifically, infections like congenital cytomegalovirus and rubella, hemolytic disorders, or certain inborn errors of metabolism. If Diamantoni had found any of these other problems, then he could confidently say that measles wasn't the cause. But if he hasn't, the only obvious cause left would be measles.
Third, Diamantoni is wrong to believe that a spleen must be quite enlarged to be fragile and at risk for rupture. Even mild or moderate enlargement of the spleen due to measles can still make the organ vulnerable to rupture. Also, a fragile splenic capsule can be difficult to determine post-mortem. It would have been of value here to look at the remaining splenic tissue to determine the presence of cells typically found during measles infection, such as multi-nucleated lymphocytes. This would have further solidified the case for measles virus as the cause of the splenic fragility. Perhaps this was done; if so, it should be reported to the public.
A few days later, in response to several days of reporters trying to get a straight story from the coroner, Diamantoni acknowledged that measles was documented as a contributing factor in the death. Diamantoni further explained that measles was listed under Part II of the infant's death certificate, which reports "other contributing conditions contributing to death but not resulting in the underlying cause." He said that this was listed on the death certificate to offer "a broader view of the general health of the child."
Diamantoni's clarification only caused more confusion. The critical question is clear: Would this infant have died if he hadn't been infected with measles? Although the press and public have grown increasingly frustrated with Pennsylvania Gov. Josh Shapiro (D) and the state's department of health for failing to make the cause of this child's death clear, the confusion lies with Diamantoni.
What do we know? We know that this infant was infected with measles while in the womb; we know that the infant died of splenic rupture; we know that measles infections can increase splenic fragility leading to rupture; and we know that splenic rupture is extraordinarily rare in newborns. It's understandable that Diamantoni is cautious about determining why this child died of splenic rupture given its rarity. Nonetheless, if Diamantoni is going to claim that measles wasn't the precipitating cause of this child's death, he is going to have to do a much better job of explaining why it wasn't.
A version of this post originally appeared in the Beyond the Noise Substack.
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