‘A clear picture of poisoning’

The Kremlin continues to deny that Navalny was poisoned, but Russian doctors suspected it all along

On Monday, September 7, Russian opposition figure Alexey Navalny was brought out of his medically induced coma. He remains in intensive care at the Charité Hospital in Berlin, where he is receiving treatment for poisoning from an organophosphate (OP) nerve agent from the “Novichok” group. Meanwhile, the Kremlin continues to deny the very fact that Navalny was poisoned, citing the results of tests conducted in Russia. On the other hand, “Meduza” has discovered that the doctors who treated Navalny in Omsk immediately suspected that his symptoms were from nerve agent poisoning — but establishing a diagnosis was made difficult because his range of symptoms was not fully consistent with the effects of organophosphate poisoning (some symptoms seemed to be missing, while others were atypical). Chemical weapons experts who spoke with Meduza believe that poisoning from Novichok-type nerve agents may well have blurred the clinical picture.

The day after Alexey Navalny was brought out of his medically induced coma, Alexander Sabaev, who treated the opposition figure in Russia from August 20–22, spoke out about the diagnosis. Sabaev — who is not only a doctor (the head of the acute poisoning department at Omsk’s Emergency Hospital Number One), but also a public official (the Omsk Region’s chief toxicologist) — said, “This isn’t ‘Novichok,’ unequivocally, it isn’t an organophosphorus compound, it’s not poisoning at all. This is an illness. It’s a metabolic syndrome. This is a metabolic coma, which happened as a result of a metabolic disorder, it progressed rapidly.”

Ever since the doctors treating Navalny at the Charité Hospital in Berlin announced that he was poisoned with a cholinesterase inhibitor, Sabaev has been consistently denying their reports. And Sabaev’s rhetoric isn’t just a personal opinion: in fact, it’s Russia’s official position on what happened to the opposition figure.

The official position

The Doctor’s at Omsk’s Emergency Hospital Number One disagreed with the conclusion that Navalny had been poisoned from the moment Berlin’s Charité Hospital made the announcement. As Alexander Sabaev said on September 3, “metabolic disorders are coming to the forefront, which isn’t characteristic of poisoning with organophosphorus substances.”

Navalny’s samples were tested at three independent laboratories, but “there were no organophosphorus substances detected [...] neither in the blood, nor in the urine.”

“So-called mediator syndrome is characteristic for organophosphorus poisoning, manifesting itself in a somewhat different clinic. Yes, the patient had a mosaic of symptoms. But they were mosaic and short-term, and therefore treated with atropine,” said Sabaev, referring to a medication used as an antidote to certain types of nerve agent and pesticide poisonings. Moreover, according to him, if an OP were used to poison Navalny “symptoms of intoxication would have been observed in the people around him, but this didn’t happen.”

At the hospital, Navalny was diagnosed with high blood sugar and “other signs of a severe metabolic disorder,” Sabaev claims — and they therefore came to the conclusion that the “reasons for his condition were not at all related to external factors.”

Police officials have stuck to this same version of the events — they’ve been conducting a preliminary investigation into Navalny’s sudden illness for three weeks (but have yet to open an actual case). According to Sergey Potapov, the acting head of the Russian Interior Ministry’s Siberian Federal District Investigative Department, police officers have examined the hotel room where Navalny stayed in Tomsk (Navalny was flying from Tomsk to Moscow when he suddenly became violently ill, forcing the plane to reroute to Omsk), studied the routes he traveled, seized the trash from the cafe at the Tomsk Airport where he drank tea before his flight, and watched the video footage from surveillance cameras. Navalny’s biomaterial samples have been analyzed, along with his clothes. The cabin of the plane where Navalny fell ill was also swabbed for evidence.

Police officials in Tomsk sent a request “for legal assistance to the relevant authorities in [Germany],” but claim they “have yet to provide any answers.” “Without concrete data from the German side it’s difficult for us to work on this topic,” said Potapov. “To date, material and preliminary investigations have not confirmed the fact that any illegal actions were committed against citizen Navalny. The preliminary investigation is ongoing.”

“Before the patient was sent to Germany, numerous analysis and tests [conducted on Navalny] didn’t reveal any poisonous substances. We are certainly interested in establishing the reason for what happened to the Berlin patient. Our investigative agencies are carrying out the necessary verification activities,” said Kremlin spokesman Dmitry Peskov.

The doctors in Omsk observed signs of organophosphate poisoning, but also atypical symptoms

After the Charité Hospital released its first confirmation that Navalny’ was poisoned, Sabaev reacted immediately, stating that when he was admitted to hospital in Omsk the doctors didn’t observe a clinical picture characteristic of poisoning with this type of substance.

But that’s not really the case. Two sources directly involved in the consultations among doctors in Omsk told Meduza that the patient showed a “clear picture of OP [organophosphate] poisoning” — but they also observed atypical symptoms. A Meduza source familiar with the results of Navalny’s examination also confirmed these claims.

Navalny showed signs like narrowed pupils (miosis), hypersalivation, sweats, and muscle twitching (hypertonia), which are all typical of organophosphate poisoning. At the same time, the consulting physicians didn’t observe any signs of bronchospasms or excessive discharge from the lungs (bronchorrhea); and Navalny didn’t have any gastrointestinal problems, like vomiting or diarrhea, while in intensive care.

Navalny’s atypical symptoms included ketoacidosis — a condition typically caused by low insulin, for example, due to diabetes. Two sources involved in Navalny’s medical consultations told Meduza about this; as did Navalny’s doctor Anastasia Vasileva (the head of the independent medical workers’ union Doctors’ Alliance), who cited information provided by the opposition figure’s wife, Yulia Navalnaya. According to one source involved in the consultations, this made it possible to assume that Navalny’s experienced a drastic sugar spike while on the plane.

The data from the toxicology tests, which were sent to the hospital, didn’t help establish a diagnosis. The toxicologists who conducted the tests in Omsk said they found no traces of toxic substances in Navalny’s samples, two of the consulting physicians told Meduza. The samples were sent to Moscow for further testing, said intensive care specialist Boris Teplykh (one of the doctors called in to consult on Navalny’s case) in conversation with Meduza.

The two doctors who spoke to Meduza didn’t see the toxicological analysis. “I saw only standard biochemistry, in which there were explicit [signs] of an acid-base imbalance and a carbohydrate imbalance,” a source involved in the consultations told Meduza. According to Boris Teplykh, the toxicologists from the lab at the Moscow Medical Center for Forensic Medicine verbally conveyed which types of poisoning they had ruled out as a result of these tests. “First and foremost, they said they checked for organophosphorus substances and ruled them out,” he said in an interview with Meduza.

However, since Navalny had clear signs of OP poisoning, the doctors in Omsk injected him with atropine — an antidote for certain types of nerve agent and pesticide poisonings. He received the first dose while still in the ambulance, a source familiar with Navalny’s medical examinations says. The source suggests the first dose of atropine could have relieved any lung and gastrointestinal symptoms, which Navalny might have experienced on the plane.

Doctors continued treatment with atropine once Navalny was in intensive care, but stopped after several doses because Navalny developed severe tachycardia (increased heart rate), a source involved in the consultations told Meduza. “A standard dose of atropine is one milligram. In the case of poisoning, the dose can be much higher, up to 100 milligrams, but we couldn’t risk it,” Meduza’s source says.

Intensive care specialist Boris Teplykh also confirmed the fact that Navalny was treated with atropine. He later clarified that the doctors decided to interrupt this course of treatment after several doses. Teplykh refused to give a comment for this article, citing the fact that he is “involved in proceedings, which are under investigation.”

Atropine and tachycardia

Tachycardia is often observed with the introduction of large doses of atropine as an antidote for OP poisoning (in other words, this is an expected result of using atropine to treat poisoning from Novichok group substances). According to the scientific literature on treating OP poisoning with atropine, tachycardia isn’t considered a reason to stop treatment.

During the two days that Navalny spent in intensive care in Omsk, he continued to show clinical signs of OP poisoning, two sources involved in the consultations on his treatment told Meduza. This was also confirmed by a source familiar with the results of Navalny’s medical examinations.

Novichok-type poisoning can blur the clinic picture, chemical weapons experts say

In conversation with Meduza, two doctors involved in the medical consultations in Omsk maintained that the clinical picture inconsistent with poisoning (in particular, the lack of lung and gastrointestinal problems) could be explained by the fact that Alexey Navalny “was poisoned with a mixture of two components.”

However, experts specializing in OP poisoning have a different, simpler explanation. Biochemist Zoran Radic, an associate adjunct professor at the University of California San Diego’s School of Pharmacy and Pharmaceutical Science, has been researching the work of cholinesterase and modeling its interactions with toxic substances for years. He believes that the mixed and atypical picture of poisoning that the Russian doctors described could be the result of the difference between the poison itself and other, well-known chemical warfare agents.

“Each nerve agent has its own toxicokinetic characteristics: that is, the time that it takes for it to be distributed through tissues depends on the structure of the substance itself. The increased stability of ‘Novichok’ and the solid, powder form [in which it can be used], can slow down [its] effects [on the body]. For example, [when the substance enters the body] through the skin,” Radic explains. “But because of this, it can more easily accumulate in tissues, especially fatty ones, and in this case, the slow intake of the poison can prolong the period during which the poisoning occurs, thereby complicating treatment.”

According to one of Novichok’s original developers, chemist Vladimir Uglev, it’s most likely that Navalny came in contact with the poison through his skin and clothes. “Alexey [was exposed to] Novichok mainly through his skin from contaminated clothing, which correlates fairly accurately with the dynamics of the development of the damage,” Uglev told Meduza.

Recognizing ‘Novichok’

Despite the high-profile poisonings — and the fact that since June 2020 poisonous substances from the Novichok group have been blacklisted under the Convention on the Prohibition of Chemical Weapons — very little is known about Novichok-type nerve agents.

Practically everything the general public knows about “Novichok” comes from one the developers behind the project — Vil Mirzayanov, who published a book about the formulas for these substances in the United States in 2007.

The formulas Mirzayanov published are used to model the possible chemical and toxicological effects associated with substances from this group. And military chemists in different countries are working on synthesizing these substances, without publishing the results of their research. There is only one known scientific article that describes experiments with a substance synthesized according to Mirzayanov’s formula. The experiments were carried out in Iran back in 2016, but the article about them is mainly devoted to the synthesis process itself and the chemical properties of the substance.

The Iranian study doesn’t contain any data on the substance’s effect on living organisms. How the poisoning manifests itself can be judged via theoretical modeling — which is also based on the chemical structure of the substances Mirzayanov described, as well as from the memoirs of chemist Andrey Zheleznyakov, who was accidentally exposed to a Novichok-type nerve agent in 1987, while working on chemical weapons (he died six years later). Detailed data on the 2018 poisoning of ex-spy Sergey Skripal and his daughter Yulia with a substance from the Novichok group has not been published.

As Mirzayanov says, and as follows from the formulas he published, different substances in the group have different chemical and toxicological properties, so poisoning from each of them can look different. “Several [types] of ‘Novichoks’ were developed in a solid, powdery form, but others, as a rule, tend to show better stability in water,” UC San Diego professor Zoran Radic told Meduza. “For example, compound A-234 is about a thousand times more stable in a solution than the nerve agent Sarin. Consequently, and this was already demonstrated in the Skripal poisoning incident two years ago, people can be exposed to the powdered poison through the skin, but the poison itself can remain in its active form in the surrounding environment for a long time.”

Meduza interviewed other chemical weapons experts who maintained that the “mixture of two components” hypothesis isn’t necessary for explaining Navalny’s atypical symptoms. One expert noted that in reality, a “classical” picture of OP poisoning can be much more varied than is commonly believed. Even such “canonical” symptoms of cholinesterase inhibitor poisoning, which are also the ones that manifest themselves most quickly, aren’t seen in all known poisoning victims, according to studies about the use of Sarin in Syria, for example. The absence of bronchospasms (as described in the typical military use of chemical warfare agents) is also not unusual among victims who came in contact with the poison in a form other than inhaled gas.

Text by Svetlana Reiter and Alexander Ershov

Edited by Dmitry Kuznets

Translated by Eilish Hart