ALL THAT GLITTER IS NOT GOLD

     All that glitter is not gold is old saying and in medicine sometimes we have patients that remind me of that. In medicine we try not to have 2 diagnosis in a given patient to explain the symptoms. But sometimes the modern day tests are done and then we have to do work up. That brings me to the story for today.

    I have known this patient for last may be 10 years and he was late sixties and had diagnosis of chronic obstructive disease. He had continued to smoke. He had some exertional shortness of breath and had some cough  But overall he was stable and continued to smoke . Now a days we do CT SCAN once a year in smokers or ex- smoker for 14 years. So I did new CT scan and this time it showed a nodule or density about 1.5 cm and there was some cavitationin it. The cavitation sometimes indicates infection .But there were some other much smaller nodules also. I was concerned about the him having cancer. So I did PET scan, In PET scan we give glucose and that is picked up by every cell in body. The cancer cells have higher metabolic rate that normal cells and so they pick up glucose much more avidly. So based on the activity, which is reported as SUV - the chance of cancer can be determined . Obviously lower uptake ,the chance of cancer is low . So I di bronchoscopy and PET scan . 

   The PET scan showed increased uptake in the nodule . The bronchoscopy showed no cancer - though with such small nodule bronchoscopy is not 100% accurate. But the bronchoscopy showed atypical TB called MAC. Now I was stuck as I was not sure if he had 2 things - cancer and MAC infection . He had COPD and some what limited lung capacity. The MAC infection is treated with 3 antibiotics for 12-18 months. So I had 2 options -one was to treat MAC infection and then do new CT scan in 3-4 months and see if the nodule decreases. But that duration of therapy may not show much change if it is MAC With cancer also it may or may not change in such a short time. The other choice was to do a different biopsy of the nodule - fine needle aspiration or navigational bronchoscopy and biopsy. 

    I decided to start treatment for MAC and asked interventional lung specialist to see him and do new biopsies . 

    The new biopsies were done and it showed -- findings consistent with infection -MAC. 

     SO HE HAD ONLY ONE DIAGNOSIS.