Sunday, October 15, 2017


                 I have been in medical practice for many years . More I see , more I realize that NOTHING is perfect. I guise that patients when they come to doctors do not read books and so the presentation of these patients is not always like it is  written in books. . So sometimes it is not perfect  or 2 plus 2 does not make 4. And sometimes you come across these patients in clusters. So this brings me to today's story.

                    I saw this 67 years old male patient for abnormal CT scan of the chest . He was a smoker and he had quit few years ago .He had some cough and he had some clear sputum . He had no fever and had not noticed any blood in sputum . He had though lost 15 lbs of weight in last 3 months and upon questioning , he told me that the food did not taste the same , and so he was eating less and so he lost weight . He did not have any excessive sweating at night . He had chest x- ray and then when it was noted to be abnormal , he had CT scan of the chest . The CT scan of the chest showed a cavitary area in the upper lobe . I told him and his wife that this could be cancer or infection . Or it could be TB . Sometimes we have a tumor blocking the secretions and then that can lead to pneumonia and then the middle part of the pneumonia can liquefy and that can look like this . But sometimes infection without tumor can also have similar appearance . Sometimes TB can look like this  and the RB is more common in upper part of the lung .
           So we did PET scan and bronchoscopy . The PET SCAN showed that the area in the upper lobe was quite hot and there were some lymph nodes that were hit too . These nodes were not seen enlarged on CT scan . I did the bronchoscopy and it did not show any blocking tumor or for that matter any abnormality . The abnormal area was quite large and was almost 10-12 cm and was occupying the entire upper lobe. So I did not do any biopsy . The breathing test did show some reduction in the reserve , but it was adequate for the surgery , in case we decided to take out the upper lobe. There were no cancer cells in the cytology of the samples that I collected .So I spoke to a surgeon and he saw the patient . He decided to do the bx of the lymph nodes first and then if negative , consider taking out the lobe .
        I was OK with it till I got a call from Lab on the samples that I had sent was growing TB like bacteria . So now I am now faced with the decision . This is a ex smoker and the positive PET scan could be due cancer or TB or infection . The lymph nodes could also be due to cancer or infection . Sometimes cancer and infection or atypical TB could be in same patient at the same time . So what should be the next step . Should we do the biopsy and the surgery to take out part of the lung > or should we treat the atypical TB and then do the follow up CT scan . The problem with this approach is the CT scan may not improve in 2 or 3 months. So no change in the CT scan does not mean that atypical infection is not the cause and it does not rule out or rule in cancer . Doing surgery in this patient and then if the surgery shows only Atypical TB , then we have done major surgery for medically y treatable infection , which can be cured by medicines in most cases and surgery in not needed. But it is  cancer and infection together, then the waiting is is not good option , but open biopsy is the only thing that can give us 100 % answer.

      This is what I call medical practice and the Watson -computer can not solve and it becomes art and the science together . 

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