How sepsis killed Muhammad Ali

It’s killed a soccer star and a super model. It’s even overpowered a Superman and a man of god. In April, it killed stage and screen star Patty Duke. And now, it’s taken the life of The Greatest.

This indiscriminate assassin is sepsis, and most people have little understanding of what it is and how easily it could affect them. That’s because the word “sepsis” isn’t used as often as it should be to explain cause of death.


(Photo by Anwar Hussein/Getty Images)

What is sepsis?

Sepsis, sometimes called blood poisoning, is essentially a complication of infection. It sounds harmless enough, but it can be deadly if it progresses to septic shock, defined by a dangerous drop in blood pressure. In 2009, Brazilian model Mariana Bridi da Costa developed sepsis that stemmed from an untreated urinary tract infection. Desperate to save her life, doctors first amputated both her hands, then both her feet, then they removed both kidneys, and finally part of her stomach, all in vain.

In 2011, fellow Brazilian, soccer star Sócrates, was rushed to the hospital three times in four months for an intestinal infection, which ultimately led to sepsis and his death. And when Christopher Reeve died in 2004, his cause of death was listed as heart failure, but he had succumbed to an infected ulcer that had turned septic. Even Pope John Paul II’s death in 2005 was noted as infection from a urinary tract infection. But the real culprit was, in fact, sepsis. In April, Patty Duke’s death was attributed to a ruptured intestine, which caused bacteria to leak into her bloodstream, again causing sepsis.And now, according to a Muhammad Ali spokesperson, his death last week was attributed to “septic shock due to unspecified natural causes.”

These are all notable names, but, according to Statistics Canada, some 30,000 ordinary Canadians also contract sepsis every year, with one in 18 dying from it, a mortality rate higher than heart attack or stroke. And these deaths don’t necessarily originate from a urinary tract infection, ulcer or ruptured intestine. Sepsis can start from a simple cut or scrape that gets infected and spreads. Your body’s natural reaction to that infection is to trigger its immune system to destroy the bacteria. But sometimes that system overreacts and starts attacking its own tissues and organs, causing them to shut down.

How is sepsis diagnosed and treated?

The only way to survive severe sepsis — and most do, although some are left with permanent organ damage — is to recognize the signs and get medical help immediately. But even then you might be misdiagnosed, since the symptoms can mimic many other conditions, such as the flu. Or a workout.

“If you run up a couple of flights of stairs, you would have all the signs that you might see for sepsis: increased heart rate, breathing hard, a little hot,” says Dr. Paul Kubes, PhD, who studies complex immune responses, including sepsis, at his research lab at the University of Calgary. “You could have a ruptured appendix, you could have sepsis, or you could have just run up the stairs.”

That challenge — detecting who’s septic and who’s got the flu, as well as the specific type of bacteria that’s causing the sepsis — is what drives Kubes’ research at the University’s Alberta Sepsis Network, a collective of 25 specialists, including immune experts, microbiologists, biochemists, infectious disease physicians, and intensive care doctors. The team is currently studying the potential of MRI screening to detect sepsis.

In the meantime, doctors typically run lab tests on blood and urine, check for clotting problems, electrolyte imbalances and abnormal organ function. Treatment depends on the severity, and could include antibiotics, intravenous fluids, corticosteroids, insulin or surgery.

Sepsis on the rise?

According to StatsCan, incidences of sepsis-related deaths increased between 2000 and 2007, then leveled off until 2011, the last year for which numbers are available. And, although it strikes all age groups, more men than women are affected, as are the very young and very old, and those with chronic disease and weakened immune systems.

Some experts believe the increase is due to the fact we’re all living longer, and living longer with chronic illness. We’re also getting more invasive procedures — everything from knee surgeries to organ transplants — that leave the door open for bacteria to wade into the bloodstream. We’re also being treated with more immunosuppressant drugs for auto-immune diseases such as rheumatoid arthritis, type 1 diabetes, psoriasis and multiple sclerosis. And then there’s overuse of antibiotics, which have not only blunted their effectiveness, but, according to Kubes, have messed with our microbiome.

“It’s a fine line; you need to give antibiotics to patients who are sick, but unless you have a good diagnosis, you’re going to give them to a lot more people than you need to,” he says. “And the ones who don’t need them, are they now going to come down with other diseases because you’ve altered their microbiome and hurt their bacterial flora?”

Kubes’ research has also revealed some surprising after-effects on sepsis survivors.

“We did a cognitive test on patients two years post-sepsis and discovered cognitive impairment. For example, an accountant couldn’t read a spreadsheet, and a colleague could barely run half a clinic a week. We think that during sepsis, the injury is not just to various organs, but to the brain,” he explains.

Early detection and prevention

In British Columbia, the BC Patient Safety & Quality Council, in collaboration with UBC’s Evidence 2 Excellenceorganization, which works to improve outcomes in emergency rooms, designed and implemented sepsis protocols in hospitals, where sepsis is sometimes contracted.

“Since 2006, we’ve been working with emergency departments to improve early detection and awareness of sepsis, [to determine] which patients may need prompt antibiotics, IV fluids and monitoring,” says Dr. David Sweet, a critical care and emergency medical physician at Vancouver General Hospital and lead sepsis consultant for both BCPS&QC and E2E. “And in the last two years we’ve been working on protocols for the nursing wards to identify patients early [to see] if they’re getting a new infection, then to look at things like their blood work and organ function, [which may] necessitate earlier treatment so it doesn’t progress to sepsis.”

Sweet says they’re also testing a pilot program that would allow paramedics to identify sepsis and alert the ER en route to the hospital. That early detection is vital — it can improve your chances of survival by 50 per cent. In fact, a study in the U.S. showed that, after six hours, each hour in delay of treatment caused a seven percent decrease in survival. But treatment within the first hour of a drop in blood pressure gave an 80 per cent chance of survival.

Predisposition and prognosis

Research is ongoing to determine if there is a predisposition, or genetic component, to developing sepsis.

“Where I’d like us to be in 10 to 15 years is to have 1) a better understanding of individual genomics, so that people will know their predisposition to developing sepsis, 2) [a way to look] at different aspects of the body’s innate immune system and identify earlier when it is dysregulated; 3) rapid ways of identifying exactly what the infection is,” Sweet says. “This may come down to microbiological techniques that detect the DNA of the actual infecting microbe very quickly.”

That research is in Kubes’ wheelhouse, but the challenge comes down to funding, like in the case of Patty Duke.

“Patty Duke battled mental health, and after she died, they set up a foundation for mental health,” he says ruefully. “I’m not knocking any other disease, but sepsis is a very important disease. It’s kind of like falling off a ladder, breaking your neck and dying, then having a foundation launched to stop people from falling off ladders. Sepsis is not sexy but it kills a lot of people. And what killed Patty Duke was sepsis, not mental health. We need funding for mental health, no question, but we need funding for all diseases.”