Case Records of the Historical Grand Rounds:
Case 4: Eleanor Roosevelt

 

Eleanor Roosevelt (1884-1962) serving as UN ambassador

Undoubtedly one of the most prominent and influential women in American history, Eleanor Roosevelt became known as the "First Lady of the World" for her human rights work and extensive social activism. She also helped form the foundation of FDR's career, and was instrumental in his reentry into politics following his paralysis from poliomyelitis. The disease that ultimately lead to her death is somewhat complicated and controversial, so for the sake of objectivity I will present it from the perspective of a physician seeing her during a hospital stay in July, 1962. All details are public record of course.

A 78 year-old woman with a history of aplastic anemia (diagnosed in 1960) presents with a chief complaint of fever. For the past four days she has recorded fevers up to 104F along with chills and night sweats. The fever has been persistent and began two days after a routine blood transfusion. She has noticed low-grade fevers after transfusions in the past but nothing this severe. She also endorses a non-productive cough that has been worsening over the past 2-3 weeks, as well as weakness, fatigue, and easy bruisability that have been worsening over the past four months. Review of systems is otherwise negative. She has been receiving regular blood transfusions for the past year to treat chronic macrocytic anemia and thrombocytopenia. She was started on 20mg prednisone three months ago to help with her increased symptom burden and "stimulate the growth of red blood cells and bone marrow." Her most recent hemoglobin was 7.9 and a bone marrow biopsy from last year showed hypocellularity with 5% myeloblasts. She has no known sick contacts or recent travel, but has been to the middle-east and sub-Saharan Africa several times over the past decade.

On exam the patient is febrile (104.5F) and appeared fatigued with scattered ecchymoses and conjunctival pallor. Examination of the heart, lung, and abdomen revealed no abnormal findings. There was no photophobia or neck stiffness. Laboratory findings included pancytopenia and an ESR of 128. Chest x-ray done shortly after admission showed scarred lungs but no signs of acute infection. Blood cultures were drawn and the patient was placed on empiric penicillin and streptomycin, though they were discontinued on day 4 as cultures showed no growth. Repeat bone marrow aspiration showed no changes from her previous study. Six days after admission the patient's fever went down to 99F and an extensive conversation was held regarding goals of care. The patient said she would never want to die in a hospital and expressed an interest in returning home. She was subsequently discharged with a diagnosis of "Fever of Unknown Origin".

While there is a wide differential for Eleanor's acute presentation, which single diagnosis explains her entire medical history? What test would you have sent (in 1962) to confirm it?

Answer (highlight to see): 
Diagnosis: Miliary tuberculosis with bone marrow infiltration 
Test: acid fast smear and culture from a bone marrow biopsy