Sunday, May 19, 2013


  When I started the medical school , in the first term of clinical medicine , we started seeing patients . The interaction was what I was looking for  the most . But I was disappointed , when in in the beginning of the  term , We were told to get the demographic data . The name age , date of birth , race occupation and so on . I thought this was useless and wanted to jump to the chief complaints and then the history , examination . I felt that this simple information was useless . We were taught that this may give use the 'clue ' to the diagnosis . But I did not want to be Sherlock Homes and Watson , I wanted to be a Doctor , who had 'great diagnostic skills .'But soon I realized that this information may be useless in many cases ,( as these cases  may be straight forward,) it adds to the diagnostic tools . The case that I am going to tell is one such rare case .
    I had known this 58 years old lady for sometimes . , may be 2 or 3 years . She had mild asthma . This would get really bad when she got respiratory infection . Then she would need lot of medications , even needed steroids . She was also admitted to hospital on few occasions . She was reluctant to use medicines all the times as she was OK when she did not have infection. One day she called me , with the complaints of bronchitis . I started her on antibiotics and course of steroids . She felt little better , but still had lot of cough and low grade fever . So at the end of 7 days I ordered the chest X-ray . To my surprise , it showed the pneumonia . I decided to admit her , as she had not responded to the out patient treatment . She was started on intravenous antibiotics and we did the CT scan . I also consulted an infectious disease specialist . The CT scan showed  large area of consolidation with central air. This was suggestive of abscess- --or pus in the middle . We continued to watch her . She continued to have fever though low grade . Her cough continued and she was also short of breath . After 8 days or so of the treatment , there was no response . She still had 100 f temperature and was still not feeling good . No cultures were positive . I did a bronchoscopy , and it had not provided any answers .I talked to the  infectious disease  doctor and then decided to do the 'open biopsy ' . I discussed with patient and consulted a thoracic surgeon , to do open biopsy .
     The surgeon saw her and did agree to take her to surgery .The lobe of the lung was heavily consolidated and he took out the entire lobe , one third of the lung . After the surgery she did very well. The fever was gone and she was eating better and white cell count came down . The pathology on the lung showed 'pneumonia'. So in a way we were not any closure to the diagnosis  than before . She was better and doing fine , but we still did not know the cause of the pneumonia .
   Then I got the call from the micro. lab. The lung specimen was growing a mold called Trichosporium .This is a mold which can occur in soil and usually does not affect patient with normal immunity . So how did this lady got it ? On further questioning I came to know  that she had no place to stay on regular basis . She used to go to one or other friend and stay with them for short time . She would do household chores in return or help them  if they are sick or need some physical help . Few days ago she was staying with a friend who needed help with her horses . She fed them and massage them and other thing with the horses , whatever is needed on day to day basis . She did not have place to sleep in the house . So she did sleep in the stable on the floor . My feeling is that she inhaled the mold from the soil or the hay and then the mold invaded the lungs . May be because she had bacterial infection , may be because of asthma her 'clearance' was not good or may be she got steroid . This led to the infection .
     SO THE OCCUPATION OR WHAT KIND OF WORK ONE IS INVOLVED IS IMPORTANT IN THE DIAGNOSIS OF THE CONDITION . ( I don't think that knowing the type of work that she did would have made me think of this unusual infection or saved the surgery .)

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