Sunday, September 22, 2013


   We as human beings want to be right all the times . May be it is related to our ego , when we are right , it gets satisfaction  or may be we enjoy telling " I told you so ", or may because we think we are smarter than other people. It does not matter , as to why we want to be right , but one thing for sure , we like to be right . It becomes more important if we are making money , like in investing in 'right' stock ' or 'real estate ' . or when people appreciate  our prediction being right .In medicine it nourishes my ego . I have written some incidences ,where i was very happy that my diagnosis was correct (and others had not suspected it ) , But today I am going to tell a story that was different .
    I had known this 80 years old female for last 3 or 4 years . I had seen her for pneumonia and then followed her periodically , though not that often . But I also saw her husband . He was coming to me for last 5 or 6 years .He had atypical TB called MAC . I treated him for a year with 3 different medicines and his CT scan had improved  . He hated the medicines due the side effects . But took them as I had told him . There is always a chance that the infection can come back , so I continued to do the follow up . He was 4 years older than her  and she always came with him and always had questions for me .
    Then it happened . She had some belly pain and her doctor ordered CT scan of the belly . With CT scan of the belly , some lower area of the cheat is also included . The belly was OK and her pain was gone , but the left lung showed some fluid  around it .So she came to me . She had no shortness of the breath, no fever or any other complaint . She was 'fine '. I did the CT scan of the chest and it showed the same fluid around the lung and no other findings, that could tell more as to why she had the fluid . I decided to do the thoracentesis , in which I take out the fluid by putting in a needle and catheter in the chest .She was going on a vacation and was anxious to get this done . So  I did it soon and took out 1000 ml of the fluid .She went out of the country for 2 weeks . The fluid showed the characteristics of inflammatory fluid . There was no cancer or TB . But cancer can not be ruled out 100 %by one test . So when she came for follow up I did a  new X-ray , It showed the fluid . The fluid that I had removed and the X-ray that had improved , was now cloudy and the fluid was back . I was not happy The fluid had come back in less than 3 or 4 weeks . I did not want to do the procedure again .So I suggested that she should see a chest surgeon . She wanted me to do. second tap .I agreed to it . The second tap yielded the same findings . The same levels of proteins , and no cancer or infection . She agreed to do a follow up X-ray . The X-ray was done . And it showed the fluid was there .This time I had taken out 1200 ml of fluid . I had talked to her several times and was telling her to get the 'open ' biopsy . My point was that , we did not know what was causing the fluid and we needed to 'fix' the fluid . In such case the chest surgeon would do the biopsy , and then put in a talcum powder . This causes adhesion and so the fluid stops coming back .We had no choice . I was worried that she had cancer , but was hoping that it would be an inflammation . She had no symptoms , so this could be a nonspecific chronic inflammation .
    She agreed and was seen by the surgeon . The operative note stated ,"clear fluid , no cancerous growth , proteinacious  material seen and biopsy done ."She did have talc put in and then in about 3 days was discharged .
    The biopsy came back as MESOTHELIOMA !! I had thought of cancer as the cause of rapidly accumulating fluid . But mesothelioma s not on my mind . So I was partly right , but not happy .

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