Saturday, March 3, 2018

EXCEPTION TO THE RULE

      In medicine we were told that when we see patients , and the patient has multiple complaints , try to find out one diagnosis . In most of the patients , one diagnosis explains all or most of the symptoms. Try not to have more than one diagnosis. Again this did not apply to the things that patients had it like hypertension and diabetes and the heart attack history. So if one comes in with shortness of breath and headache and fever  and say chest pain , try to find out one diagnosis to explain all the symptoms . Once one is in medicine for many years , he finds out that there is always exception to the rule. So the story of my patient that I am going to tell one such story .
         I saw this patient for abnormal chest CT scan  He had cough and had chest X - ray and it showed some nodule and so the PCP did chest CT scan and then the CT scan was abnormal and so he was sent to me . He was 70 years old male and had history of heart attack and had some high blood pressure. He had cough and some white sputum . He had not lost any weight and has no fever and no weight loss. He had cough for may be 3 months . He was not smoker . The CT scan showed multiple nodules . All of them were very small. they were like dots and some may be like small pea. The PET scan , which picks up cancer in 85 % of the cases of the cancer , has limit on the size and so these were too small to be picked up . The PET scan needs size of at least 8 mm, preferably 10 mm. The nodules were 3-4 mm . The needle biopsy of then nodules was impossible as they were too small. The open biopsy could be done , but which nodule and with the given size and the lack of any symptoms , we decided to d the bronchoscopy to rule out atypical TB called MAC.

    The bronchoscopy was negative for cancer and the other tests on the lavage and the bushings were also negative for cancer and the TB or any mold .So we decided to do the follow up on the CT scan . I followed him for year and half and the CT scans .Some of the nodules disappear and some got smaller.. His cough was better and he had no other problem . He came for the follow up. I did Ct scan after 2 years  and it showed that one of the remaining nodule has grown . So I did PET SCAN . The PET scan did show activity in that nodule . He also had some other smaller nodules and they did not get picked up on PET scan..I did do new bronchoscopy and the work up was negative for cancer . But I was concerned and so We did needle biopsy of the nodule that had grown . It was cancer - type of  a cancer that is treated with chemo.But at the same time I got the report on the bronchial lavage , it showed MAC - atypical TB .

     So we had 2 different diagnosis. -both of them will need treatment at the same time.