As a pathologist I had a visit from TB. Typical story: autopsy on undiagnosed case. The case? A woman about age 60 or 70 who was to be discharged from the hospital the following day, but decided to die first. This was about 50 years ago and I don’t remember too many details about what her organs looked like, but apparently not too alarming. In any event, my exposure was apparently sufficient to change my skin test to positive. (I was lucky and did not medicate or ever have any positive chest X-rays.)
The second case was quite different. A middle-aged lady entered the emergency room and was tentatively diagnosed as a possible carcinoma of the esophagus. Why? Because she was about 5 ft 6 in tall and weighed 60 lbs. At autopsy she looked like those pictures one sees of holocaust survivors who have starved in Nazi concentration camps. Every rib clearly visible. When her chest was opened, her lungs were composed of numerous golf ball size cavities. (And yes, I was wearing a mask.) The clinical story was that for some reason, she refused to see doctors, in spite of the fact that her husband worked in food service at our hospital. She died within 24 hours after admittance. What this case illustrated most clearly was why tuberculosis was called “consumption,” it literally consumes the flesh. Also why the famous Dutch and other artists often portrayed beautiful female subjects as what we would today consider too plump. They were obviously the healthy ones who didn’t have consumption.
After these experiences with undiagnosed TB, I decided to do a limited chart study of the previous decade in our hospital. One case stands out in my memory. The patient was before my time. He was perhaps in his fifties and was admitted with symptoms of a chest infection. Several features stood out. He was in the hospital, I believe, for 23 days before he expired. During that time he was in a half dozen or so rooms, all semi-private in those days and presumably moved pair him with another male patient. The nurses’ notes all mentioned that he was coughing a lot. But what most caught my attention was that he had two X-rays, one upon admittance and one shortly before he expired. Both were described as showing “a diffuse micronodular infiltrate.” But there was no mention of the possibility of miliary TB, which is, of course, what he had at autopsy. All of which aptly illustrates the old medical axiom that most diagnoses are missed, not because the physician was not capable of making the diagnosis, but just because he didn’t think of it.
Gordon Short, MD
Image by CDC.org