Thursday, February 24, 2011

Eleanor Roosevelt's miliary tuberculosis---the most fabled diagnostic error in the history of medicine, or not?

For over 20 years following the death of Eleanor Roosevelt various stories of her final illness circulated around. The gist was that she had miliary Tb which for months was misdiagnosed as an idiopathic disease (aplastic anemia by most accounts) and erroneously treated with prednisone. Now that her medical record has been unsealed for over 20 years you might think we'd have pat answers about what really happened, but we don't.

I recently blogged it here and linked to a story published in Medscape. That article by Albert Lowenfels, MD, based on his review of the medical record, was pretty straightforward and seemed to confirm some of the accounts we'd heard: that Roosevelt's original hematologic disorder was actually tuberculosis involving the bone marrow. Did that constitute a medical error? Maybe not. Although in retrospect she was misdiagnosed and inappropriately treated for months, misdiagnosis does not equal error.

I have since found another version of Roosevelt's diagnosis and treatment and now things get a little muddy. That account, written by Dr. Barron Lerner, implies that the original diagnosis of aplastic anemia was correct. Later, some weeks before it grew out of her final bone marrow aspirate, Tb was considered and two antituberculous drugs (INH and streptomycin, the only ones they had then) were started because by then her illness had evolved from pancytopenia with febrile reactions to transfusions to FUO.

To make it even more interesting, both authors indicate Roosevelt had a resistant organism, but differ on the type of resistance, one saying the infection was resistant to streptomycin and the other saying it was resistant to both drugs.

So if this was a diagnostic error it was likely without consequence given the resistant organism. It's not at all clear, though, that the misdiagnosis was due to error unless, as implied in this CCJM article, it was a case of VIP syndrome in which the ordinary principles or care were compromised because Eleanor Roosevelt was a VIP:

A striking example of the potential effects of VIP syndrome is the death of Eleanor Roosevelt from miliary tuberculosis acutissima: she was misdiagnosed with aplastic anemia on the basis of only the results of a bone marrow aspirate study, and she was treated with steroids. The desire to spare this VIP patient the discomfort of a bone marrow biopsy, on which tuberculous granulomata were more likely to have been seen, caused the true diagnosis to be missed and resulted in the administration of a hazardous medication.11 The hard lesson here is that we must resist the pressure to simplify or change customary medical care to avoid causing a VIP patient discomfort or putting the patient through a complex procedure.

But that doesn't make a lot of sense either because a bone marrow aspiration hurts a heck of a lot more than the biopsy.

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