ONE AND MANY

      Sometimes we see things happening to someone , who has bad things happen to him/ her . Then he gets better and comes out and then again an another calamity hits him. I often wonder as to why this happens . But then when you see the 'etiology' or reason for that , we realize that the cause or causes have common thread. This brings me to story for today. 

   I have known this patient 80 years old or so now for many years. He has been smoker and had COPD - the disease related to smoking. He had continued to smoke in spite of diagnosis of lung problem due to smoking. But then he had abnormality on his chest X-ray and so I did the work up . He had cancer of the lung. Fortunately he was a  surgical candidate and so thoracic surgeon did surgery and part of his lung was removed and he did OK. He continued to smoke and I continue to do follow up in office and CT scan . It looked like he had developed some scaring in the area of the surgery, but since the CT scan was abnormal I decided to do bronchoscopy. This time I saw something on his vocal cords - he had cancer . I sent him to ENT physician and then he was sent for radiation treatment . He did OK. He continued to smoke though had reduced. 

     Next few years I continued to see him . He had lost weight and had some exertional shortness of breath. He also needed some oxygen. Then he was hospitalized and the chest x- ray showed large area of pneumonia. I did not see him during that hospitalization . NO CT SCAN WAS DONE - not sure why. He came to me for follow up and so I decided to do further work up. We did bronchoscopy and also PET SCAN as the density was large almost more than 3 inches .I also did bronchoscopy and his vocal cords were normal and there was no cancer in the bronchial tubes. But the PET SCAN was abnormal. There was no activity on vocal cords and the density that was seen on chest x- ray was not there but had a scar in that area and he had some nodules with some activity. BUT there was new mass in a sinus! and that had very high uptake suggesting  a cancer in sinus. I am  not sure on the new nodules in lungs . But this patient who had lung cancer which seems to be cured and had vocal cord cancer and that also seems to be cured -now has new cancer most likely in sinus.SO IT WILL BE 1-2-3!

IT IS NOT POSSIBLE !

      In medicine I never say never. This is due to the uncertainty of medicine. In medicine there are 3 factors  namely Host -Agent and Agent. So depending upon all 3 the response is determine. The agent may be same and it can cause different response in different hosts  and the host may be the same and the agent may be different and the response will be different and the same with reaction between the different agents and different hosts and different environment ,that the response will be different. The example would be mold in home or office and all the people working there have same reaction or may be not the same degree of reaction. Not everybody have same nasal allergies with allergy pollen season. This is known , but then sometimes we have problem with diagnosis as the incidence of allergic reaction is not known, This brings me to story for today.

     This patient came to me for evaluation of possible asthma. He had seen different lung specialist and had severe asthma diagnosed and has been treated with many different medicines and he still had problem. He was offered  additional treatment with biological shots and he did not want it. I tested him for allergies , There is a immune globulin called IgE. which is elevated with allergies and that was markedly elevated and he has several allergies on testing for allergies , but most of them were mild. The option of treatment was limited with allergies and severe asthma needing steroids many times. I also did CT scan of the chest and he had lots of mucous and dilated  bronchi - what we could see in uncontrolled asthma. To see if he had additional fungal infection I did bronchoscopy and tests came back OK

    I talked to him and adjusted meds and offered him biological shots and he wanted to wait. He did do better with my medicines , but the CT scan did not show much improvement . He still had congestion. Then one day he came back for follow up and his lungs were clear and oxygen was normal. He was happy and I was happy. And so I said to him that 'looks like the medicines are working .' Then he said 'But I am not taking medicines .'NONE AT ALL '.He said I stopped all the medicines.

    I was stunned , but thought that there must be something in his home or office or surroundings that was causing his asthma and somehow he must have eliminated it . And I was correct but not in the sense that I thought. HE HAD STOPPED STATINS THAT HE WAS TAKING . I did do new CT scan of the chest . And the lungs were almost clear.

    I continued to do follow up and for last 2 years he has not had much problem and he has not taken asthma medicines on daily basis. He still needs inhaler PRN. - as needed especially when he has resp infecetion. But otherwise he has no problem . 

   So, it seems like he had allergies to STATIN THAT CAUSED THE LUNG INFILTRATES AND AGRAVATED HIS MILD ASTHMA . I have not know this allergy . So my statement that ANYTHING UNDER SUN INCLUDING THE SUN CAN CAUSE ALLERGIES is true