Eleanor Roosevelt’s TB: The mystery continues
How’d she get drug-resistant TB?
Most medical school residents have heard the story of how Eleanor Roosevelt died of TB. Thanks to Barron Lerner, MD — Columbia University medical sleuth, internist, and author of the book The Breast Cancer Wars — most TB folk also now know that contrary to med-school legend, doctors didn’t botch the former First Lady’s diagnosis, nor did they fail to spot the miliary TB that swiftly overcame her.
Instead, a study of Roosevelt’s chart — which Lerner discovered sitting idly in a file cabinet where anyone could have taken a look at it — shows physicians had the results of Roosevelt’s sputum-smear culture in hand several weeks before she died. The chart also shows plainly why the anti-TB treatment given to her failed, Lerner adds. According to posthumous resistance testing, Roosevelt was resistant to both streptomycin and isoniazid. Along with PAS, those were two of only three anti-TB drugs available at the time; unfortunately, they were also the two with which she’d been treated.
Still, Lerner is continuing to refine the details of Roosevelt’s final days, he says. That’s partly because people still call him up to argue evidence one way or the other, or to relate fresh anecdotes. Take the debate over how, exactly, she came to acquire that drug-resistant TB.
Check out the chronology
In 1919, when she was 35 years old, Roosevelt suffered an episode of what her physicians called pleurisy, Lerner says. "Clearly, it was a lung infection of some kind — and chest X-rays taken subsequent to that episode show scarring consonant with TB," he notes. That primary infection couldn’t have been drug-resistant, though — since in 1919, neither streptomycin nor isoniazid had been discovered. So that final illness couldn’t have represented a reactivation of the initial bout of "pleurisy," right? Well, maybe so; but maybe not, Lerner says.
One possible explanation is that instead, Roosevelt had the bad luck to encounter drug-resistant TB at some point later on in her life. She was, after all, known for her ardent and influential crusades in defense of the poor and the downtrodden. Her travels took her to any number of places where drug-resistant TB might already be fomenting — Indian reservations, urban ghettos, a settlement for indigent miners, and a raft of third-world countries.
What lends weight to this scenario is that her final illness, whatever its exact causes, clearly left her immune system suppressed, Lerner points out. "She clearly suffered from bone-marrow failure," he says. Physicians considered, but soon ruled out leukemia as the cause, which left two possible culprits — aplastic anemia, or TB of the bone marrow (or, perhaps, both). In any event, doctors prescribed steroids, further compromising her immune system’s ability to fight off TB bugs that might have come her way.
So she died of a drug-resistant super-infection to which she was vulnerable, right?
Except for one small hitch . . .
Yes, except for one small problem, Lerner says. Sometime after that 1919 episode of pleurisy, Roosevelt was given a five-day course of streptomycin for a minor infection. If her bacillary load had still been substantial at that point, it’s possible the five-day course of antibiotics made for just enough drugs (and just enough bugs) to induce resistance. By that reasoning, during her final illness, doctors were inadvertently giving their patient monotherapy with INH — which could have brought on INH resistance.
The problem with this scenario is that patients with pleural TB generally don’t have a bacterial burden high enough for a five-day course of drug therapy to have produced resistance. So the argument continues, Lerner says. "Some people like one explanation; others like the other. I suppose it’s everyone according to their own gestalt." Someone told him recently that he should write a story about writing the story of Mrs. Roosevelt, he adds. "Certainly, I’ve gotten a lot of interesting feedback from a lot of people."
[Editor’s note: For more on Eleanor Roosevelt’s death, see Lerner’s most recent article on the subject, published in The International Journal of TB and Lung Disease’s December 2001 issue; and also Lee Reichman’s Timebomb (New York City: McGraw-Hill; 2002), pp. 19-20.]
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