A QUANDARY (CONQUEST OF DEATH 13)

ACUTE CONSUMPTION

Weary, sullen, mournful face
A tale of internal disturbance tells
Perhaps of some chronic illness,
Or of current affairs!

Dark rings around the eyes
Malar prominence and sunken cheeks,
Malar flush of high fever,
Makes the diagnosis more clear

Clinicians! Beware! Pay attention!
It may be acute consumption!

(Note:--The first episode of acute consumption i.e.  Acute miliary tuberculosis may masquerade as Acute Bronchitis.)

I had written this poem and shared it with my students to make them aware of the uncommon presentations of common diseases.

I myself was caught unawares in a similar quandary.

I was called to give opinion on a patient admitted to the female ward.

“Nurse, where is the patient that is referred to me?” I asked the nurse in charge of the ward.

“Bed number eighteen.” She replied

“Nurse, will you please chaperon?

She did.

The patient was a middle aged woman. I started asking her history. Wasted, weary and wan, she hardly had enough energy to answer my questions. With great effort she pointed to her abdomen and said,

“p-a-i-n--- s-u-d-d-e-n--- p-a-i-n--- h-e-r-e”

The nurse started narrating-----

“About a month back, she was admitted for high fever.”

“How high?’ I enquired.

“102 degrees F. She used to have fever every day. So her Widal test (a blood test for typhoid fever) was done. It was positive. So antibiotics were started. Even after five days, her fever has not come to normal. Now since the last two hours, she has developed abdominal pain along with some distension of the abdomen. We gave injection to relieve her pain but no relief----“

She was emaciated, her eyes sunken, her cheeks sunken, her tongue dry and pale but definitely not coated, her nails pale, her abdomen scaphoid (concave abdomen)-----

Obviously, she was chronically malnourished. Her ‘general look’ was ashen, cadaverous.

Her abdominal signs were suggestive of perforation.   

”Typhoid perforation?” I raised a suspicion.

“That is what our doctors suspect”, the nurse added.

“Let us get an x-ray of her abdomen done” I suggested.

“Meanwhile, tell me about the pattern of her fever” I asked the nurse.

“Every day, exactly at 11 A.M., she starts getting high fever up to 102 degrees F. Throughout the day, the fever remains high. But surprisingly in the morning, she has no fever. Up to 11 A.M, her body temperature remains normal”, replied the nurse.

“This means that at some time in the night, her fever abates” I commented.

“Yes”, the nurse agreed

“Do you sweat at night?”, I asked the patient.

She nodded.

This made me skeptical about the diagnosis of ‘typhoid fever’.
The wet plate of her x-ray film was ready. The signs of perforation were inviting me to explore her. I decided to discuss the problem with the physician and the anesthesiologist on duty.

“What is the cause of the perforation?” I raised a question.

“Typhoid!”, exclaimed the physician. “Her Widal is positive”.

“We don’t treat reports; we treat patients” I started arguing “Clinically, the pattern of fever does not fit in with the ‘typhoid type’! If this is typhoid, she should have responded to the therapy, but she has not! When well selected drugs fail, we should revise our diagnosis!! Positive Widal could be an example of anamnestic reaction (false positive)!!---“

“Well, well, she needs exploration! No question about it!!”, the anesthesiologist intervened. “With a calculated risk, I shall give anesthesia! You do a fast job! OK??” 

I started the exploration. She had a stricture (narrowing) in the terminal ileum (far end of the small intestine) and a perforation proximal to it. The findings of exploration were suggestive of tubercular perforation! I sutured (stitched) the perforation and performed ileotransverse anastomosis (joined the end of the small intestine to the transverse portion of the large intestine). I washed the peritoneal cavity (the cavity in which the intestines are contained), put a drain in the peritoneum and closed the abdomen.

I sent her blood for bacterial culture for typhoid. I started empirical treatment for tuberculosis. In due course, her blood report arrived. It was negative for typhoid!

So my diagnosis was correct.

She tested all of us right from the word go. Her wound healing was delayed. This was understandable because she was severely malnourished. Even after correct diagnosis and treatment, not only did her fever not abate but it also remained at a higher level. Well, in tuberculosis, especially with toxemia (toxins circulating in blood), the fever lingers longer, and also goes at a higher range.

Against all odds, about six weeks later, her fever abated and she started picking up health.

After about ten weeks later, we discharged her. She attended the clinic for follow up regularly.

Though it took quite longer than expected, she recovered very well from her ‘typhoid’, AKA TB, the great masquerader!!

A TRUE STORY IN REAL LIFE

A DRAMA IN MY LIFE!!