Portal de Periódicos da CAPES

The Reply

2015; Elsevier BV; Volume: 128; Issue: 10 Linguagem: Inglês

10.1016/j.amjmed.2015.04.038

1555-7162

Gino Fornaciari,

Zoonotic diseases and public health

The finding of a document with a description of the conditions of Francesco I in the last moments of his life is of particular interest, as it allows us to further clarify the causes of the Grand Duke's death. In this document the symptoms presented by Francesco are petechiae, fever, and swollen neck. Prof. Lippi concludes that this account "supports the conclusion of poisoning" of a previous work1Mari F. Polettini A. Lippi D. Bertol E. The mysterious death of Francesco I de' Medici and Bianca Cappello: an arsenic murder?.BMJ. 2006; 333: 1299-1301Crossref PubMed Google Scholar, because "skin eruption (such as petechiae), fever and swelling are symptoms of acute arsenic poisoning." In acute arsenic poisoning, skin rash is described, but only in the form of flushing erythema or maculopapular eruption.2Uede K. Furukawa F. Skin manifestations in acute arsenic poisoning from the Wakayama curry-poisoning incident.Br J Dermatol. 2003; 149: 757-762Crossref PubMed Scopus (42) Google Scholar These findings are totally different from petechiae, historically associated with infectious diseases such as epidemic typhus, which the 16th-century physicians could certainly distinguish. On the contrary, these dermatological manifestations are described among the symptoms of malaria, and are mainly seen with falciparum species.3White N.J. Breman J.G. Malaria.in: Kasper D.L. Fauci A.S. Hauser S.L. Longo D.L. Jameson J.L. Loscalzo J. Harrisons Principles of Internal Medicine. 17th ed. McGraw-Hill, New York2008: 1281-1289Google Scholar The skin lesions consist of petechiae, which are small (1–2 mm) red or purple spots on the body and are caused by minor hemorrhages.4Khan A. Chaudhry A.A. Khan U. Falciparum—the masquerader.J Pak Med Assoc. 2012; 62 (2012): 62-63PubMed Google Scholar The incidence of malaria manifesting with purpura (diffused petechiae) is reported in the range 1.33% to 25.6%.5Godse K.V. Zawar V. Malaria presenting as urticaria.Indian J Dermatol. 2012; 57: 237-238Crossref PubMed Scopus (3) Google Scholar The second symptom mentioned in the document is fever, which is never described in acute arsenic poisoning and is instead typical of malaria.3White N.J. Breman J.G. Malaria.in: Kasper D.L. Fauci A.S. Hauser S.L. Longo D.L. Jameson J.L. Loscalzo J. Harrisons Principles of Internal Medicine. 17th ed. McGraw-Hill, New York2008: 1281-1289Google Scholar With regard to the "swollen neck," although it is a very generic symptom that is not helpful in the diagnosis, it is well known that swollen neck lymph nodes are a common sign of many infections, not of intoxication. Finally, as already discussed in the comments to the original paper,1Mari F. Polettini A. Lippi D. Bertol E. The mysterious death of Francesco I de' Medici and Bianca Cappello: an arsenic murder?.BMJ. 2006; 333: 1299-1301Crossref PubMed Google Scholar there are no evidences of arsenic poisoning of Francesco I, simply because the toxicological analyses were carried out on very questionable soft tissue remains,6Fornaciari G. The mystery of beard hairs.BMJ. 2006; 333: 1299Crossref PubMed Google Scholar, 7Ottini L. Who is who, that is the question.BMJ. 2006; 333: 1299Crossref PubMed Scopus (26) Google Scholar which most likely cannot be attributed to Francesco. On the contrary, ancient Plasmodium falciparum proteins were detected in the skeletal remains of the Grand Duke, demonstrating without any doubt that he was affected by falciparum malaria at the time of his death.8Fornaciari G. Giuffra V. Ferroglio F. Gino S. Bianucci R. Plasmodium falciparum immunodetection in bone remains of members of the Renaissance Medici family (Florence, Italy, sixteenth century).Trans R Soc Trop Med Hyg. 2010; 104: 583-587Abstract Full Text Full Text PDF PubMed Scopus (31) Google Scholar I am grateful to Prof. Lippi for having found the Vatican document, which further supports the diagnosis of severe, acute malaria as the cause of death of Francesco I de' Medici. Still About Francesco de' Medici's Poisoning (1587)The American Journal of MedicineVol. 128Issue 10PreviewIn 2010, Fornaciari et al1 detected Plasmodium falciparum in the skeletal remains of Francesco I de' Medici (1541-1587), Grand Duke of Tuscany. Francesco and his wife died within a few hours of each other, with the official report giving the cause as pernicious malaria. However, others suspected they had been poisoned by Francesco's brother and successor as Grand Duke, Ferdinando. The Fornaciari group argued that their findings confirmed the official explanation of Francesco's death and removed any suggestion of poisoning, although toxicologic studies published in 2006 had found arsenic concentrations within the lethal range in the remains of Francesco and his wife. Full-Text PDF