THE OLD DICTUM IS NOT ALWAYS CORRECT

     When we were in medical school , we were told that one does not  need of try to explain the symptoms with 2 different diagnosis . When a patient  is having some complaints , we should not have 2 different diagnosis to explain the problem . And that is true in many conditions and also in most patients .But sometimes we have 2 different diagnosis and then it becomes difficult to 'work up ' for 2 different diseases. This brings me to the story for today. 

    I had seen this male patient may be 3-4 years ago . He was admitted with pneumonia - 6 or more months ago and was seen by lung specialist .He was a smoker and had abnormal chest x- ray and then CT scan chest . He was treated with antibiotics and also  had bronchoscopy. He was discharged and was told that looks like he had cancer  and no diagnosis was done . He and his family were not happy and so they came to me. I reviewed the scans and the reports and realized that he had bronchoscopy and the samples - which take 6-7 weeks to finalized - was positive for atypical TB called MAC. I explained him the reports and started him of 3 different antibiotics  that needs to be continued for 18 months. I did tell them that he had abnormal CT scan and that needs to be followed as he could still have cancer. He was a smoker and had COPD. He did not have good lung capacity - reserve to do open lung biopsy.

    We followed him and did new CT scan several times and that continued to show improvement and the nodules that we were concerned had become smaller. We di complete the MAC medicines and then did CT scan and it continued to show improvement. Then last one was a problem . He had no new complaints and he had done sputum for TB - MAC and that was OK and the Ct scan showed that one of the nodules ,which was very small , like 4-5 mm or 1/5th of an inch , had doubled in size- still less than 10 mm or less than half an inch. I was concerned and I had interventional lung specialist do biopsy. This is relatively new procedure - may be 4-5 years old where computer guides to do biopsy in right segment and so the yield is high. This is more effective and when patient is not a good candidate for open lung biopsy due to poor lung capacity , we can get diagnosis. So the biopsy was done and HE HAD CANCER . So he did have MAC and he did respond to treatment - and he DID NOT have cancer 3-4 years ago - but now he has cancer .