Saturday, July 24, 2021


   In out life we often have to make decision daily as to do things this way or that way . Take this road or do highway. order this food or that food . Take a phone call from this person or not . But in medicine we make the decision which is some times more complex that ordering topping on pizza. In many cases the flexibility of decision is not there. If I see elevated blood pressure or blood sugar, there is no question about if we should treat it or not .We treat it -period. But in certain other condition, we have to make a decision. This brings me to the story for today. 

   I saw this 91 years old male patient for the cough . He had cough off and on for 3-4 months  and he had no shortness of breath or other complaints . He was not a smoker and though was 91 years old , he was overall OK . He had some memory problems but lived by himself  and had not lost weight or had fever . He did not have history of asthma or gastroesophageal reflux - the 2 most common causes of chronic cough The Chest X- ray was done  and that had nothing impressive but some upper lobe scars. So I did some more testing . I di CT scan of chest and that showed some upper lobe scars  and some other abnormality that could go for Old TB. I was concerned  and so I did not do breathing test  and instead I gave him an inhaler for possible asthma  and I asked him to do sputum for tb bacteria. I had planned for doing the breathing test, but his sputum came showing that it was growing TB bacteria. This was preliminary  and the final report in case of TB can take as much as 6 weeks . Some times we can get report in 3-4 weeks if the TB bacteria is of type that grows fast . I had planned to do breathing test but I cancelled it till I get the culture. 

    I called the patient and the son and told them that the sputum is growing something and to be on safe side keep him indoor. Then they came to see me after 2-3 weeks . By then I had received the identification of the bacteria . It was atypical TB . The Mycobacteria is a family name  and the Mycobacterium Tuberculosis is the one which is contagious and MUST BE treated and isolate in the first few days  and also family close contact will be needed to be checked . But the mycobacteria are not like that. They do need prolong treatment and have similar symptoms ,but they are not contagious.So when they came to see me ,I had to decide on the treatment . I had 2 choces one was to treat this 91 years old patient with 3 MDICINES for 18 months or not to treat but watch it . tHt medines used can have liver problem , eye problem . So I had to talk to them . Her was a 91 years old patient who had sputum growing atypical TB  and had no complaints other than some cough. 


I decided to watch him with new CT scan and new sputum check and clinically. 

Sunday, July 18, 2021


    We have a saying in medicine . We never say never in medicine. I have written many a times on unexpected and surprises that we see in different patient. But in spite of knowing that we never say never in medicine , things seem to come as surprise  and then we say "there is exception to every rule". That brings me to the story for today . 

  I had known this lady for many years . Her husband was may patient and he had cancer of the lung and when we diagnosed it he had spread of the cancer to liver and he did survive for 4 years or so . She started seeing me after he had died . She had also smoked and she had COPD  and we did the work up. She then developed lung cancer. She was 'lucky' and we had diagnosed the cancer in time - or at least we thought. She did ok but when the surgery was done she had some of the lymph nodes showing spread of cancer. So we did have her see oncologist and had treatment with chemotherapy. She continued to do OK and she had COPD  and she had shortness of breath and needed oxygen .She also had gained weight and she had sleep apnea . I had told her after the diagnosis of the cancer  and the need for the treatment to 'prevent' the recurrence that the recurrence happens most in first year and then less in second  and least in third year after the diagnosis. After 3 rd year the chance of recurrence is not there  and so you are cured if there is no evidence of cancer after 3 years . 

   Five years had gone by after the surgery and she had new scan. She had CT scan and then PET scan. That was abnormal and so she came to me. Five years had gone by since we had diagnosed cancer and she had surgery. So the possibility of old cancer coming again was low or not there . But patients who have one cancer have high chance of having second cancer is high and then depending upon the type of cancer the treatment may be different. The abnormality was in such a location that simple way to do the biopsy was not possible . I spoke to interventional radiologist and he did not feel he could get it and suggested that biopsy with ultrasound guidance through a bronchoscope was better choice . But the interventional pulmonologist did not feel EBUS or navigational bronchoscopy could get the diagnosis. I did ot want open biopsy as this was not a curative surgery and she was oxygen dependent COPD . So the risk was higher . But I had no choice  and so she did see the surgeon and had a biopsy  and it was NOT A NEW CANCER but it was the SAME CANCER that was taken out 5 years ago.