What killed Otto Warmbier? Maybe an infection or blood clot

Pneumonia, a blood clot, kidney failure or sepsis could have killed Otto Warmbier, but he almost certainly never had a chance of recovering, neurologists said Monday.

Warmbier's family said he died Monday afternoon, just days after he was returned unconscious and unresponsive from North Korea.

North Korean officials said he had been in a coma for more than a year — right after he was sentenced to 15 years of hard labor in prison for allegedly having taken a propaganda poster off a wall. North Korean authorities said the strapping, 21-year-old college student had taken a sleeping pill after he fought a bout of botulism.

RELATED: Reaction to the death of Otto Warmbier

Reaction to the death of Otto Warmbier
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Reaction to the death of Otto Warmbier
.@POTUS and @FLOTUS Offer Their Deepest Condolences, Thoughts and Prayers to the Family and Friends of Otto Warmbie… https://t.co/JEoOCx9El7
Karen & I are so saddened to hear this. We're praying for Otto's family tonight. A tragic example of North Korea's… https://t.co/kvgYAZM2mV
Otto Warmbier should never have been in jail for tearing down a stupid banner. And he most certainly should not have been murdered for it.
Secretary Tillerson: We hold #NorthKorea accountable for Otto Warmbier’s unjust imprisonment. https://t.co/MwHNCuUjyw
Saddened by death of Otto Warmbier, tortured & murdered by #NorthKorea - US should not tolerate such hostile action https://t.co/91GnTgSh1h
Gov. John Kasich on the passing of Otto Warmbier: More details: https://t.co/O58kfBhR8T https://t.co/X63cBvjiLx
This is incredibly sad. https://t.co/YLdjZRQlT5
Just learned that Otto Warmbier, the young man held captive by savage N Korea has died. Heartbroken for his parents. Prayers for the family.
We are deeply saddened by the tragic loss of Otto Warmbier, a remarkable young Ohioan: https://t.co/qSGnPcJQra
My thoughts and prayers are with Otto, his parents, and the entire Warmbier family. https://t.co/z1b6EbgDoX
Very sad to learn of the passing of Otto Warmbier. As a parent, I can't imagine what his parents have had to go through.
Otto Warmbier, the US student held prisoner and severely mistreated in North Korea for 17 months has died. #RIP #NeverForget
My heart goes out to the loved ones of Otto Warmbier. Thinking of Otto's family & friends, & wishing them strength during this tragic time.
My full statement on the passing of Otto Warmbier: https://t.co/KT538qw6tb
Ambassador @nikkihaley on the passing of Otto Warmbier: "Our prayers are with this fine young man’s family and comm… https://t.co/pHBSlYiKfU

Doctors who examined Warmbier said they found no evidence of botulism, a kind of food poisoning that can be deadly but that usually does not cause brain damage. Warmbier's father Fred said he didn't believe that's what happened to his son.

Related: Otto Warmbier Dies Days After His Return from North Korea

What doctors at the University of Cincinnati hospital did find was extensive brain damage that looked like it could have been caused by a long period of oxygen deprivation – the kind caused when something stops someone's heart.

"His neurological condition can be best described as a state of unresponsive wakefulness," Dr. Daniel Kanter, director of the hospital's neurocritical care program, told a news conference last week.

There's not much hope for someone after that, neurologists agreed.

"If they are in that state from a lack of oxygen to the brain ... and it has been more than three months ... the chance of anyone having a meaningful recovery — I don't know if any of us have ever seen it happen," said Dr. Lori Shutter, professor of critical care medicine, neurology and neurosurgery at the University of Pittsburgh Medical Center.

Related: Three Americans Still Held by North Korea

A "state of unresponsive wakefulness" is the more modern way of describing a persistent vegetative state — when the brain stem keeps people breathing, waking and sleeping, but there's no conscious brain function, Shutter said.

"Patients who are in a persistent vegetative state after a cardiac arrest have a very low rate of recovery," added Dr. Andrew Naidech, neurocritical care physician at Northwestern Memorial Hospital in Chicago.

Warmbier's quick death suggested he was not in good health, Naidech and Shutter agreed. Doctors also agreed it was unlikely his family decided to withhold food and water — a perfectly valid decision for someone with such a poor prognosis, but they said it takes patients more than just a few days to die from dehydration.

RELATED: Otto Warmbier: A timeline of the student's North Korea imprisonment

Otto Warmbier: A timeline of the student's North Korea imprisonment
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Otto Warmbier: A timeline of the student's North Korea imprisonment

January 2016: Warmbier is imprisoned in North Korea, charged with stealing an item that had a state propaganda slogan on it.

March 2016: Warmbier is sentenced to 15 years of hard labor in North Korea

March 2016 - 2017: The United States advocates for North Korea's allowing Sweden access to Warmbier and three other American citizens, pushing for their release.

January 2017: President Trump is inaugurated as the 45th president of the United States, signaling a seat change in American foreign diplomacy.

February 2017: Secretary of State Rex Tillerson briefs President Trump on the situation surrounding Warmbier's imprisonment in North Korea.Trump directs Tillerson to take all appropriate measures in securing the release of U.S. hostages in North Korea.

May 2017:  The U.S. State Department and North Korean Ministry of Foreign Affairs hold a meeting in Oslo, Norway, during which they agree to the Swedish Embassy in Pyongyang's access to all four detainees. Sweden is later granted these visitation rights, prompting North Korea to request a meeting with the United States.

June 6, 2017 - State Department Special Representative Joseph Yun meets with North Korean ambassador Pak Gil Yon at the United Nations in New York. Yun learns during this meeting that Warmbier has been in a coma for over a year.

June 6-11, 2017: Secretary of State Tillerson instructs Yun to travel to North Korea with the mission of bringing back Warmbier. They travel with a medical team to Pyongyang.

June 12, 2017: Through Yun, the United States is able for the first time to confirm Warmbier's status. The U.S. demands Warmbier be released on humanitarian conditions. North Korea complies.

June 13, 2017: Warmbier is evacuated from North Korea, travels to Ohio where he will reunite with his family.

June 13, 2017: Otto Warmbier arrives home to Cincinnati, Ohio
June 15, 2017: Otto Warmbier's father, Fred, speaks out during a press conference on his son's return home.
June 15, 2017: Doctors give updates on Warmbier's status during a news conference at the University of Cincinnati Medical Center in Cincinnati, Ohio.

"The fact that he died so quickly suggests he was getting some sort of medical treatment that could be withheld," Naidech told NBC News.

"If this young man was in this state for an extended time period, once the family heard everything, they may have started to focus on quality of life," Shutter speculated.

If he had pneumonia, a urinary tract infection or a bloodstream infection, the family may have decided to withhold antibiotics. Pneumonia is possible because people in unwakeful states can easily aspirate saliva into the lungs, where it can cause infection. Urinary infections can be caused by prolonged use of a catheter, and they can become serious.

Related: Warmbier Has Extensive Brain Damage

"They may have felt that this quality of life would not be of the type that they would feel Otto would have wanted," Shutter said. "They may have 'let's make him comfortable'."

But Dr. Daniel Laskowitz, a professor of neurology at Duke University, said something sudden could have happened — such as a pulmonary embolism.

"Why would you die suddenly after 15 months in a persistent vegetative state?" Laskowitz asked. There are usually two reasons why you pass away in that setting. One is infection," he said.

The second would be a blood clot.

"If you are in a persistent vegetative state and you are just immobile for a prolonged period of time, you have a propensity to form a clot," he said. "That can be catastrophic and precipitous."

The long flight from North Korea to Ohio could have made a blood clot even more likely to form or break off and travel to the lungs, Laskowitz said.

No matter what it was, Warmbier's state almost certainly resulted from poor care in North Korea, Laskowitz said. He said it's somewhat feasible that Warmbier could have suffered from botulism and that if he was given a sleeping pill while already paralyzed from the botulinum toxin, that could have caused him to stop breathing and his heart to stop, leading to brain damage.

Shutter, who trained several members of Warmbier's medical team when she was at the Cincinnati medical center, said he would have been given the best care possible at the Ohio facility.

"I do feel for this family," she said. "But I do feel they had one of the best teams in the country to help them with that."

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