Woman's death calls gene therapy into question

By Carla K. Johnson and Lindsey Tanner

updated 1:15 p.m. ET Sept. 16, 2007

TAYLORVILLE, Ill. - A few hours before she died this summer at the age of 36, Jolee Mohr lay in a Chicago hospital so swollen by internal bleeding and her failing kidneys that her husband decided against bringing their 5-year-old daughter to say goodbye. The girl wouldn’t have recognized her mother.

Robb Mohr couldn’t bring himself to watch her die and he spent his wife’s last hours talking with her helpless and puzzled doctors. One vowed to get to the bottom of the illness, and there were several clues to go on.

The most unusual was this: Jolee Mohr fell ill the day after her right knee was injected with trillions of genetically engineered viruses in a voluntary experiment to find out if gene therapy might be a safe way to ease the pain of rheumatoid arthritis. She was dead three weeks later.

The sponsor of this nationwide experiment, Targeted Genetics Corp. of Seattle, has halted the work and more than 125 patients are being evaluated, according to a company spokeswoman. No other problems have been reported, and the company believes patients were adequately informed of the treatment’s risks.

U.S. health officials are investigating Mohr’s death, and the case is expected to be discussed Monday by advisers to the National Institutes of Health. There’s a lot at stake, including answers for Robb Mohr, and the interests of Targeted Genetics. But there are also questions about how medical studies are done and how much study volunteers are told of the risks.

“To me, it’s an avoidable death,” Mohr said during an interview at his home amid the cornfields of central Illinois. “And you’re going to have to really show me a lot of stuff to convince me that it wasn’t.”

5,000 patients involved in studies
There have been more than 800 gene therapy studies involving 5,000 U.S. patients since the NIH approved the nation’s first human gene transfer study in 1989. Yet there are no approved therapies despite 17 years of research, and the only major success — a cure for the rare inherited immune disorder known as “bubble boy disease” — came with a high cost: leukemia linked in 2003 to the virus that delivered the treatment.

Still, the 1999 death of Arizona teenager Jesse Gelsinger is the only reported fatality definitively linked with a U.S. gene therapy study, an NIH spokesman said. And Dr. Theodore Friedmann, who once headed the NIH committee that oversees gene therapy experiments, said developments in medicine often come with problems, even death.

Even if gene therapy is found to be the cause of Jolee Mohr’s death, Friedmann said, the method remains promising.

“There’s no question that this event is tragic for the family and the woman involved,” he said. “It does simply point to the fact that we have a lot more to learn.”

Living with the pain
When Dr. Robert Trapp of the Arthritis Center in Springfield told Jolee Mohr about the gene therapy study, she had lived with rheumatoid arthritis for 14 years, her husband said. She kept the pain, stiffness and swelling in her joints under control with medication.

Mohr seldom missed any work at her full-time data entry job for the Illinois secretary of state. She went to church and volunteered at the county fair. She loved to read and work in her garden. She and Robb had just bought a boat and were planning to build a new house. Their only child, Toree, was getting ready for kindergarten.

To enroll in the study, every patient had to have some form of inflammatory arthritis. Jolee Mohr had faith in Trapp, her doctor for seven years, her husband said.

“You trust your physician. He’s your doctor. You trust him like you do your minister,” Robb Mohr said.

Jolee Mohr thought the experimental treatment might relieve the chronic pain in her right knee, her husband said, though this stage of the study was simply to find out if the treatment was safe. Bioethicists talk of a “therapeutic misconception” — a belief among patients in early-stage research that they will get better.

Robb Mohr said his wife believed.

Jolee Mohr signed a 15-page consent form Feb. 12. “Knowing her, she probably didn’t read through it,” her husband said.

Chilling risks
The form mentioned some scary possibilities. It said that the genetically altered viruses in the study — called tgAAC94 — “could spread to other parts of your body. The risks of this are not known at this time.”

“We have seen this type of spread in animal studies when tgAAC94 has been given by injection into the joint,” the form said.

Altered viruses can “damage the DNA in the cells of your body by inserting itself into your genes,” it went on. “If this happens, it could put you at risk for developing cancer in the future.”

And on page 9, it said unknown side effects could result in “pain, discomfort, disability or, in rare circumstances, death.”

The study used a virus that can infect cells without causing human disease. In simple terms, the genetically engineered virus is used as a vehicle to carry a new gene into the body. Targeted Genetics hopes the new gene will help the body make a protein that would ease arthritis pain.

Dr. Trapp made a brief note in Mohr’s chart after her visit: “Discussed participation in clinical trial. Consent form received and I answered her questions.”

Mohr got the first shot of the test drug two weeks later. She was randomly assigned to get the highest dosing level on both injection dates.

Gene therapy study at a glance Goal: To find out if repeat injections of an experimental gene therapy drug were safe in people suffering from inflammatory arthritis. Who: 127 patients, all diagnosed with either rheumatoid arthritis, psoriatic arthritis or ankylosing spondylitis, which affects the spine and lower back. Where: Patients were recruited through doctors in these cities: Glendale and Tucson, Ariz.; Palm Desert and Upland, Calif.; Denver; Boca Raton, Ocala and Stuart, Fla.; Coeur d’Alene, Idaho; Springfield and Chicago, Ill.; Frederick, Md.; Reno, Nev.; Johnson City, N.Y.; Oklahoma City; Duncansville and Willow Grove, Pa.; Austin, Dallas and San Antonio, Texas; and Seattle, Wash. Sponsor: Seattle-based Targeted Genetics Corp. How did it work: Genetically engineered viruses were used as vehicles to carry an engineered gene into the body. This stage of the study was to determine safety. The overall goal is to determine whether the genes help the body make a protein that fights inflammation. What happened: Study halted after one patient died. Doctors don’t know whether the injections played any role in the death. Investigations are ongoing. Source: The Associated Press

By all accounts, everything was fine after the first shot. But she got sick the day after her second injection, vomiting and running a fever.

Recalling the sequence of events, Robb Mohr removed his wife’s calendar from the kitchen wall and carried it to the dining room table. He tapped his finger on key dates, stabbing harder on July 2.

“She got the injection on the second, we were in the emergency room on the seventh, she was admitted on the 12th,” Mohr said. He pointed to July 18, the date of his wife’s 200-mile ambulance ride from a Springfield hospital to Chicago; July 23, when he agreed to a “do not resuscitate” order and, finally, July 24, the date she died.

No obvious cause
Jolee Mohr was brought by ambulance to the University of Chicago Medical Center shortly after midnight on July 19. Doctors in Springfield had thought she might need a liver transplant and the Chicago hospital had transplant expertise.

Dr. Kyle Hogarth treated her in the intensive care unit that morning and grew increasingly concerned. After learning that Mohr had gotten sick following the July 2 injection, he reported her condition to the Food and Drug Administration as a possible serious side effect related to the study.

While a transplant wasn’t deemed necessary, Hogarth saw signs of a possible infection and that “got us very concerned about the possibility that this virus that wasn’t supposed to replicate” somehow might have spread throughout her body.

Jolee Mohr was in respiratory failure, her kidneys were shutting down and she was septic, meaning she was suffering from a life-threatening immune system reaction that can result from infection. She needed a ventilator to help her breathe, and she was put on kidney dialysis. A fungus infection was discovered throughout her body — it did not respond to medication — and Mohr developed a pool of blood in her abdomen that grew to the size of a watermelon, crushing against her spleen and kidney.

Hogarth has seen many patients that sick, but he found Mohr’s case unusual because there was no obvious cause. That made her difficult to treat, and her condition worsened.

“As she was accumulating more problems and we were making no headway, her family came to us and said she’s been through a lot ... this is not what she would have wanted,” Hogarth recalled. Already unconscious, Mohr was given drugs to sedate her even further, lifesaving equipment was removed, and she died a day later.

“The human side to this is awful — it bothered everybody on the team,” Hogarth said. “We’ve all unfortunately been around it, but this one just seemed even sadder, because she didn’t have a life-threatening illness to begin with.”

“To see someone who is otherwise young and otherwise healthy — that I think is the part that is really bothersome,” he said.

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