I have been in medicine for many years and sometimes things become routine. We sometimes feel that not much new is going to be seen especially if one is doing subspecialty and not general medicine. But then you see a case and that tells me that no 2 things are same. I see pulmonary patients and so my practice has may be 10 common diseases that I see. One of them is COPD , the disease that is caused by smoking .I see all sort of stages from mild to severe and some end stage. Due to common factor of smoking I also see patients who have COPD , develop cancer of the lung. But we also have surprises at times.
I have been seeing this patient for many years . He has been smoker and has not quit smoking even though the disease is severe. He also had diabetes and he had developed abnormal chest x- ray many years ago . We did work up and he had a cavity and it was related to atypical TB called MAC . The treatment of this MAC is prolonged and takes 18 months . So he was started on 3 medicines and then when he continued to have positive sputum for MAC bacteria ,I added 4th drug and that was given for a year . He responded to that and the sputum was negative now - showing no evidence of MAC. I told him that we can stop MAC medicines when he comes for the follow up .
I also did CT scan to follow the disease and few months ago he had some lymph node enlargement. That could be due to MAC and so I did new CT scan and the nodes were bigger . The MAC was doing better but the nodes were slightly larger. So we deiced to have him see another physician to do biopsy of the nodes . He waited for few days and then missed follow up and . So I called his wife and him and got the procedure scheduled . The biopsy was done and now he has lung cancer . The diagnosis was small cell cancer.. The small cell cancer is not surgical condition- it cannot be resected ,but can be treated with chemotherapy . With his COPD and nodes involved and tissue diagnosis of small cell cancer he is not a surgical candidate. But my problem is that I was going to stop the medicines for MAC .But now chemotherapy to be started , it will suppress immunity and that can flare up the MAC . So I am forced to continue the medicines untill such a time when and if he will be off chemo.
