She was a brilliant student. Her father, a banker, was worried about her cough and evening fevers. She ate less, would tire easily and had lost weight. A careful history, examination , a chest x ray and blood and sputum examination confirmed it as Tuberculosis of the lung. She took the treatment, followed the advice and recovered fully. In the bargain her father became my good friend. He mentioned another daughter of his who had settled in Maharashtra after her marriage.
After about 2 years, he came back with the other daughter. She was almost looking like her younger sister. She was feeling tired nowadays and had come to her parental home for a few days. She wanted a check up. Nothing particularly was complained of. On a thorough examination, I discovered mild fever and a lymph node mass with a few enlarged lymph glands sitting on the right Carotid artery in the neck. It felt like a tubercular lymph node mass (with features of matting) . Ideally a Fine Needle Aspiration or a biopsy was required to prove the suspicion. The location being tricky and the finding classical, I deferred this step in the interest of the patient a decision I regretted later. However, I explained the whole thing to her father and made him feel the gland mass so that he understood my dilemma of avoiding the procedure of Fine needle aspiration/ biopsy to avoid a possible damage to the major artery which was a more serious matter. I started her on standard doses of anti tubercular medications and monitored her temperature and weight on alternate days.
She was to go back to Maharashtra in about 2 weeks and she was much better by then. Fever had settled and she had gained about 2 Kg weight (as expected). Her father was very satisfied. She returned to her her home without any issues and started leading a normal life.
After about 5 days, she started having fever. They phoned me. I asked her to rule out Malaria which was rampant in Mangalore at that time. There was no evidence of Malaria. I asked her to contact a local doctor. What followed was unbelievable and gave me a rude shock. The local doctor on examination was able to feel lymph gland mass on the left side also and wanted a biopsy of that. It was far away from the Carotid artery and therefore it was very safe to do so and it was done. The nightmare followed. The report came as Papillary Carcinoma of the thyroid gland - a variety of thyroid cancer. The doctor even went to the extent of telling her father that the original diagnosis was indeed wrong and cancer was missed and was treated as tuberculosis, an unpardonable mistake. He phoned me and politely told me so.
Now it was my turn to get seriously upset. I had entirely depended on my "fingers" for the diagnosis - my chief always told me after 10 years of my training I was ready for the "bare hand combat" and should always trust myself. I had indeed believed him and trusted myself. I could have done at least a ultrasound scan or a CT scan of the neck and the mediastinum and picked up the "hidden enemy". Did I entirely miss the track? How could I make amends?
I suddenly realised that the whole thing depended on the biopsy done on the left side. Why not do a biopsy on the right side? Why not a CT scan to know the extent of the disease? Indeed, why not? I requested the father of the patient that they must get a CT scan of the chest and mediastinum and do a lymph gland mass biopsy on the right side also. It took me a while to convince them I also asked them to consult the senior most physician in town and lay all the cards on the table. Let him give a verdict.
The CT scan showed involvement of multiple groups of lymph glands in the neck, chest and the mediastinum. The biopsy from the neck glands on the right side revealed the presence of Tuberculosis! I was right! What was the message? There were 2 different diseases on two sides - Tuberculosis on the right side and cancer on the left side! A rare and a deadly combination indeed! The other lesson take home message was to avoid a short cut whatever the reason is. A scan would have revealed the other glands and prevented all embarassment.
There is a little more to be added. The senior physician who saw the patient and the reports thoroughly appreciated my approach for being patient friendly and using good brands of the drugs, following up the patient systematically withou admission and keeping the patients informed of everything at all times. He even advised the father of the patient to thank me. He promptly did so and we became friends again!
A hidden enemy indeed!
After about 2 years, he came back with the other daughter. She was almost looking like her younger sister. She was feeling tired nowadays and had come to her parental home for a few days. She wanted a check up. Nothing particularly was complained of. On a thorough examination, I discovered mild fever and a lymph node mass with a few enlarged lymph glands sitting on the right Carotid artery in the neck. It felt like a tubercular lymph node mass (with features of matting) . Ideally a Fine Needle Aspiration or a biopsy was required to prove the suspicion. The location being tricky and the finding classical, I deferred this step in the interest of the patient a decision I regretted later. However, I explained the whole thing to her father and made him feel the gland mass so that he understood my dilemma of avoiding the procedure of Fine needle aspiration/ biopsy to avoid a possible damage to the major artery which was a more serious matter. I started her on standard doses of anti tubercular medications and monitored her temperature and weight on alternate days.
She was to go back to Maharashtra in about 2 weeks and she was much better by then. Fever had settled and she had gained about 2 Kg weight (as expected). Her father was very satisfied. She returned to her her home without any issues and started leading a normal life.
After about 5 days, she started having fever. They phoned me. I asked her to rule out Malaria which was rampant in Mangalore at that time. There was no evidence of Malaria. I asked her to contact a local doctor. What followed was unbelievable and gave me a rude shock. The local doctor on examination was able to feel lymph gland mass on the left side also and wanted a biopsy of that. It was far away from the Carotid artery and therefore it was very safe to do so and it was done. The nightmare followed. The report came as Papillary Carcinoma of the thyroid gland - a variety of thyroid cancer. The doctor even went to the extent of telling her father that the original diagnosis was indeed wrong and cancer was missed and was treated as tuberculosis, an unpardonable mistake. He phoned me and politely told me so.
Now it was my turn to get seriously upset. I had entirely depended on my "fingers" for the diagnosis - my chief always told me after 10 years of my training I was ready for the "bare hand combat" and should always trust myself. I had indeed believed him and trusted myself. I could have done at least a ultrasound scan or a CT scan of the neck and the mediastinum and picked up the "hidden enemy". Did I entirely miss the track? How could I make amends?
I suddenly realised that the whole thing depended on the biopsy done on the left side. Why not do a biopsy on the right side? Why not a CT scan to know the extent of the disease? Indeed, why not? I requested the father of the patient that they must get a CT scan of the chest and mediastinum and do a lymph gland mass biopsy on the right side also. It took me a while to convince them I also asked them to consult the senior most physician in town and lay all the cards on the table. Let him give a verdict.
The CT scan showed involvement of multiple groups of lymph glands in the neck, chest and the mediastinum. The biopsy from the neck glands on the right side revealed the presence of Tuberculosis! I was right! What was the message? There were 2 different diseases on two sides - Tuberculosis on the right side and cancer on the left side! A rare and a deadly combination indeed! The other lesson take home message was to avoid a short cut whatever the reason is. A scan would have revealed the other glands and prevented all embarassment.
There is a little more to be added. The senior physician who saw the patient and the reports thoroughly appreciated my approach for being patient friendly and using good brands of the drugs, following up the patient systematically withou admission and keeping the patients informed of everything at all times. He even advised the father of the patient to thank me. He promptly did so and we became friends again!
A hidden enemy indeed!
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