Friday, February 21, 2020


     In medicine we like  and wish certain things  and the medical judgments are accurate in most patients . But sometimes we know what to expect and wish it is not so  and so the disappointment happens when we get what we expected but were wishing something simpler or something less toxic
Then there are cases where we think of something and get some other thing  and that was unexpected  and may be nicer or may be worse than what we thought it would be . I have seen sometimes patients who come for what looks like simple pneumonia  and then further work up shows that there is wide spread cancer which was not suspected at all.That brings me to to the story of a patient that happened sometimes ago.

     This was a 78 years old male who had smoked for many years  and he had COPD - emphysema  and he was short of breath all the time but used to travel from up north to Florida .He was on oxygen  and he did use it with sleep  and did not like to use it when he walked , though he needed it . When he came to Florida , a bladder cancer was diagnosed  and he had treatment for it  and he was doing good . He has some chest x- ray abnormality in past  and I had done CT scan  and the CT scan was stable. The problem sometimes with these kinds of patients is that due to severely impaired pulmonary status , they are not good candidate for invasive work up. So this time I did regular chest X- ray  and he had some abnormality and so I di CT SCAN of the chest . That showed some problem in the middle part or the lobe on the left and some also on right side . The possibility that a cancer could block a bronchus  and cause the collapse was there . So I decided to do bronchoscopy . I had actually expected a cancer  and did not want to see the cancer as he was not a candidate for surgery and even chemo may not be the best thing . So I did the bronchoscopy and I noticed a growth on his Vocal cords . It looked like cancer . I did not expect that . When I looked inside the bronchial tubes I did not see any obstructing cancer  and so I did some brushings  and washings  and expected that it will be OK .So I did not expect the vocal  cord cancer and he had one  and i expected the cancer in lung and he did not have it . So in a way I was happy  and I told them that we will do new CT scan  and hope that nothing new would pop up. So in 2 weeks or 3 weeks I found out that the lab called me  and he was growing an unusual bacteria on the culture. This was not expected . It was called Nocardia  and needs treatment for 6 months to 1 year with antibiotics  and the usual antibiotic is a combination of sulfa drug - simple one .But he was allergist to sulfa  and so that was added problem . So he had unexpected throat cancer  and no cancer in lungs that I though he had  and he had Nocardia that I did not expect .
      The story has happy ending , his throat cancer was treated with radiation  and he has done well. He has no lung cancer  and his Nocardia seems to to be responding very well  and his bladder cancer is also in remission. 

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