Dr Mohr’s Email Exchange with Dr. Alex Levin

When doctor Mohr accused Josh and Brenda of abusing Naomi they were desperate to find out the real cause of Naomi’s illness since neither of them had actually abused her. The Burns had many question for Dr. Mohr that she was unable to answer. She asked Josh and Brenda if she could share Naomi’s retinal scans and obtain a second opinion from Dr. Alex Levin from Philadelphia, PA who is a leading eye expert. Josh and Brenda agreed to this and anxiously awaited his opinion, but they never heard back from Dr. Mohr or Dr. Levin.

An e-mail discussion between Dr. Mohr and Dr. Levin was eventually obtained during discovery before the trials. During the Civil Trial, the e-mail was brought up during the defenses cross-examination of Dr. Mohr. During deliberations, the jury requested to read the e-mail exchange between the two doctors. The prosecution objected to this. The judge sustained the objection and would not allow the jury to see the e-mail. Any mention of the e-mail was completely blocked during the Criminal Trial.

The e-mail exchange was very important to the diagnosis of Naomi. During her stay at U of M Mott’s Children’s Hospital, Naomi had a condition known as thrombocytosis. In the e-mail exchange between Dr. Mohr and Dr. Levin, Dr. Levin wrote that the presence of thrombocytosis called into question any conclusions drawn about the retinal hemorrhages. At this point Dr. Mohr stopped all communication with Dr. Levin and failed to provide Josh and Brenda with Dr. Levin’s opinion. Even the subject line of Dr. Mohr’s e-mail reading, “tough case,” leads one to the conclusion that the presence of thrombocytosis calls into question Dr. Mohr’s conclusions and diagnosis.

 

The Exchange:


To: Alex Levin
From: Bethany Mohr
Sent: April 02, 2014 1:53 PM

Hi Alex,

I recently evaluated an 11 week-old female infant who presented with vomiting, apnea and hypothermia; who, later, was found to have right-sided seizure activity. MRI done initially was read as “normal” except for bifrontal enlarged extraaxial spaces. No infections etiology identified; CMV, HSV, etc. negative. Discharged and clinical presentation/event attributed to viral gastroenteritis with provoked seizures.

She was discharged after 6 days but presented again, only hours later, with apnea. No further electrographic seizures noted. Quickly began doing well. Extensive metabolic workup continued; ophthalmologic evaluation done to look for Glycogen Storage Disease.

But, instead, RH found! MRI re-read with subdural fluid consistent with chronic SDH; and posterior parietal and cerebellar SDH noted (based on T1/T2 on MRI, about 4-7 days old).

Had difficult birth – unsuccessful VAVD; eventually delivered by C/S.

If you have time, can you please take a look at the attached images – photos 1 day after initial bedside exam and 9 days after initial presentation; 11 days after vomiting started. My guess is that hemorrhages occurred prior to initial presentation.

Per Ophthalmology Report (exam under anesthesia): On the day of the surgery, the patient was brought to the operating room at the Mott Children’s Hospital. After verification of correct side of operation, a lid speculum was inserted into the right eye. She was already intubated due to an MRI procedure which was done earlier. Intraocular pressure measured 8 mmHg. Examination of the anterior segment with portable slit lamp showed a clear cornea with a deep anterior chamber and a round dilated iris. There was no iris neovascularization. The lens was clear. Anterior vitreous was unremarkable. Examination of the posterior segment with indirect ophthalmoscopy using a 28 as well as a 20 diopter lens showed diffuse retinal hemorrhages which were distributed interaretinally as well as preretinally. There were a few areas of possible subretinal hemorrhage as well. The optic nerve was pink and flat. Vasculature was somewhat dilated and tortuous. Retinal hemorrhages extended all the way to the ora which were seen on seleral depression. There was no virreous hemorrhage. The Fovea was clear of any hemorrhage in the right eye. Lid speculum was then placed in the left and and anterior segment examination showed a clear cornea with a deep anterior chamber. Iris was round and dilated and no neovascular tissue was seen on the iris. Lens was clear. The anterior vitreous was unremarkable. Intraocular pressure in the left eye measured 7 mmHg. Examination of hte posterior segment showed clear posterior vitreous. There was no evidence of vitreous hemorrhage. Optic nerve was pink and flat. The vasculature was somewhat dilated and tortuous. Again, similar to the right eye, there were extenstive preretinal as well as intraretinal hemorrhages throughout the entire fundus. The hemorrhages extended all the way to the ora for 360 degres on scleral depression. Following examination, fundus photography was preformed with RetCam 130 degree lense as well as 80 degree lense The fundus photography demonstrated the retinal hemorrhages as well as vasculature tortuosity in both eyes. Fluorescein angiogram was then performed using fluorescein with a concentration of 7.7 mg/kg. The angiogram demonstrated normal arterial and venous filling. There were numerous areas of focal block of the fluorescein secondary to  preretinal hemorrhages. Choroidal filling was within nomal limits with a few focal areas of blockages due to intraretinal and subretinal hemorrhages in both eyes. In the late stages of the angiogram, no leakage was seen. However, in the periphery the vasculature was dilated and tortuous. There was no evidence of any significant retinal ischemia or capillary drop out in either eye. Following angiogram, both eyes were rinsed with Bss Solution. The patient was then returned to the recovery room in stable condition.

Of note, electrolytes always normal; but, persistent thrombophilia, 600,00s-900,000s.

Your thoughts would be much appreciated.

Thanks, Bethany

 


To: Bethany Mohr
From: Alex Levin
Sent: Thursday, April 03, 2014 5:16 PM
Subject: Re: Tough Case

Impressive documentation. Very well done.

Not sure what the question is. I can’t think of another diagnosis other than abuse assuming no obvious coagulopathy or other event

Alex V. Levin, MD, MHSc

 


To: Alex Levin
From: Bethany Mohr
Sent: Thursday, April 03, 2014 5:51 PM
Subject: Re: Tough Case

Thanks – they did a really nice job!

My question was mainly about what to say (if anything) about the thrombophilia.

Sent from my iPhone

 


To: Bethany Mohr
From: Alex Levin
Sent: Saturday, April 05, 20147 11:06 PM
Subject: Re: Tough Case

Do you mean thrombocytosis?
Either way we have no idea what this might do re retinal bleeding and could be considered to throw the retinal findings into question. We just don’t know

Alex V. Levin, MD, MHSc, FRCSC


End of Exchange