The Case of the Well-Known Woman With Unexplained Anemia

Albert Lowenfels, MD

Disclosures

September 09, 2010

How Would This Patient Be Treated Today?

Roosevelt's autopsy revealed that she suffered from miliary tuberculosis with widespread involvement of major organs. Currently, miliary tuberculosis is rare, occurring in about 1% of all cases of tuberculosis.[3] If untreated or inadequately treated, the mortality rate is high; however, prompt, aggressive therapy with appropriate drugs to which the organisms are susceptible improves the survival rate. In many patients the disease is undetected during life.[4]

The key element that would have improved the chances for successful therapy in Roosevelt's case would have been earlier diagnosis. A bone marrow smear obtained late in the course of the disease was negative, and only 2 weeks before she died, culture specimens of the bone marrow finally grow out mycobacterium tuberculosis. David Gurewitsch, her personal physician and close friend, believed that the aplastic anemia, diagnosed about 2 years before the patient died, was probably caused by tuberculosis, and if correctly diagnosed and treated at that time, the patient may have survived. It is also likely that Roosevelt's steroid therapy given to treat the aplastic anemia was inappropriate in view of the final diagnosis of tuberculosis.

When Roosevelt became ill, isoniazid and streptomycin, which had been isolated by Waksman in the 1940s, were the only drugs available for the treatment of tuberculosis. Before that time, the disease was widespread, mortality was high, and bed rest, along with procedures to collapse the afflicted lung, such as pneumothorax, were the only therapeutic methods available. Today, these procedures are no longer performed and the large institutions necessary for isolation of tuberculous patients closed as soon as effective drugs became available. If Roosevelt's organisms were actually resistant to streptomycin and isoniazid, additional drugs, such as rifampin, rifapentine, ethambutol, and many other second or even third-line agents are available. It is likely that if diagnosed at the time of the original bone marrow diagnosis, Roosevelt would not have died from miliary tuberculosis.

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