The Case of the Well-Known Woman With Unexplained Anemia

Albert Lowenfels, MD

Disclosures

September 09, 2010

The Diagnosis

During Eleanor Roosevelt's final stay at Columbia Presbyterian Hospital, tuberculosis was considered unlikely by nearly all of the physicians who treated her, including a pulmonary consultant. The surprising diagnosis of widespread tuberculosis was not confirmed until a week or 2 before her death, when the culture of the second bone marrow aspirate specimen grew out mycobacterium tuberculosis.[1]At autopsy the listed diagnoses were (1) aplastic anemia; (2) extensive disseminated miliary tuberculosis involving the lungs, liver, kidneys, and bone marrow; and (3) active duodenal ulcer, thought to be steroid induced.

It is curious that several months after Roosevelt's death, a clinicopathologic conference from another hospital reported a remarkably similar patient with pancytopenia also treated with steroids. At autopsy, miliary tuberculosis, as in Roosevelt's illness, was the surprise finding.[2]

When Did She Contract the Infection?

There are 3 possible periods when Eleanor may have contracted tuberculosis:

  • Eleanor Roosevelt was doing social work in her teens, when a pulmonary infection developed that may have been tuberculosis;

  • In her 30s, when touring Europe after World War I with Franklin, she was diagnosed as having "pleurisy," but tuberculosis was also considered a possibility; or

  • In 1947, when she was 63 years old, Eleanor Roosevelt accompanied her physician and close friend, David Gurewitsch, when he traveled to Switzerland to be treated for tuberculosis. She was in close contact with Gurewitch for several days when their plane was delayed in Ireland.

A surprising feature of Roosevelt's tuberculosis is that the organisms were apparently resistant to streptomycin, making it somewhat unlikely that her terminal disease resulted from reactivation of an infection acquired early in life.[1] However, if miliary tuberculosis developed from an antecedent infection, then the aplastic anemia could be explained by tuberculosis involvement of the bone marrow.

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