05 May 2011

The VIP Treated At St Elsewhere


White House painting of Eleanor Roosevelt borrowed from Wikipedia

With the contemporary interest in morbid death pictures I couldn't resist this gem found on the way to looking up something else, this interesting article on the death of Eleanor Roosevelt. Those of you of a certain age will perhaps remember that she died at home in early November 1962 after being seen and admitted to Columbia/Presbyterian Medical Center in New York City by fairly prestigious physicians associated with Columbia College of Physicians and Surgeons, a fairly prestigious medical school amongst many prestigious east coast medical schools. This professor is also interested in medical mistakes and the part they play in morbidity and mortality statistics.

As I recall, even as long ago as medical school—and the early 60s of the last century was a long time ago—it was rumored to be common knowledge that Mrs Roosevelt died from miliary tuberculosis, a potentially treatable disease; and it seemed to be the conventional wisdom that she had suffered from leukemia or lupus which obscured the more lethal complicating tuberculosis diagnosis; and that somehow this devastating complication had been missed and untreated. At least that is how I heard the story. Perhaps this version was suggested by a similar illness discussed at a Massachusetts General Hospital clinico-pathologic conference published in the New England Journal of Medicine—much read by medical students in the Boston area in those days—a few months after her death.

So, almost fifty years later, while looking for the cause of death of some other Very Important Person, I came across a review article by Dr Barron Lerner, the Angelica Berrie Gold Foundation Associate Professor of Medicine and Public Health at the Columbia College of Physicians and Surgeons, in which he reviews the published material on Mrs Roosevelt's final illness and death and also presents his findings on review of her medical chart from Columbia/Presbyterian Medical Center, a copy of which had been on file since 1990 at the FDR Library in Hyde Park, New York; and the autopsy findings from the same prestigious hospital. That would have captured the attention of almost any older physician, all of whom have their own stories of missed diagnoses, by themselves as well as by others.

After reviewing all this material it turns out that Mrs Roosevelt had a very serious bone marrow disease—aplastic anemia—resulting in decreased numbers of red cells, white cells and platelets, a severe pancytopenia. This was thought to have first been noted by the patient in 1960, when an auto accident may have been precipitated by faintness from anemia. She was given transfusions in 1961 and also started on prednisone, the all-purpose last-rites-medication in those days. Though it apparently does not do much for aplastic anemia, not much else was available, and unfortunately for this particular patient, prednisone has a nasty habit of compromising immune function.

Of course she saw multiple doctors and endured multiple tests but she did not get better. A bone marrow aspiration was not cultured. Her chest films remained normal. Eventually she was started on isoniazid and streptomycin, the heavy duty anti-tuberculous drugs of the day, not because her physicians were convinced that was what she had but because they couldn't think of anything else to do, and tuberculosis was curable. (I wonder if the writers of House are aware of this case?) Another bone marrow aspiration and biopsy was taken, this time cultured, in the summer of 1962. About two weeks before her death, the biopsy grew some TB organisms that were eventually shown to be resistant to both isoniazid and streptomycin.

Mrs Roosevelt declined any further heroic measures. She died November 7, 1962. The autopsy was very interesting. Tuberculous organisms were grown from almost every organ tested, but she formed very few granulomas, the usual hallmark of miliary—resembling a millet seed—tuberculosis. so then, perhaps much to the relief of the physicians caring for the patient, it looked like the underlying pancytopenia (aplastic anemia) combined with prednisone led to a re-activation of a dormant and rare form of widespread disseminated tuberculosis. Even though her physicians doubted that that was what she had, she was treated as if she did, but it did no good because the organisms were resistant to the drugs available at the time. What a great story. There may be more to the story but that isn't what was told and rumored around the medical student population of the time.

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