TB or not TB

The importance of an accurate diagnosis can decide the distance between life and death, as we face the constant challenge of dealing with “mimics” in medicine.


What is the differential diagnosis?” I questioned my team, raising my arm with an MRI film in hand, holding it up against the morning light that brightened up the patient’s room. A differential diagnosis (or DD, as we like to abbreviate it) is where we list out multiple possibilities by weighing the probability of one disease over another, based on the clinical and radiological features of the patient’s symptoms, to work towards an actual final diagnosis. It is a process of clinical reasoning that we exercise to enable appropriate testing, helping us arrive at an answer.

Mrs Gandhi was a 55-year-old lady whose right eye appeared more prominent than the other. She felt pain while moving her right eyeball, and the tiny streaks of red we saw over the white of her eye looked angry and congested. The lower eyelid was swollen and appeared like a prosthetically positioned dark circle. An evening fever had been brewing in the background, but she had brushed it aside. She was capriciously told she had a tumour in the orbit and was sent to us.

The resident doctor peered at the scan, hoping I would shift focus to someone else or that my arm would tire waiting for an answer. When the diagnosis is uncertain, junior doctors don’t like to speak up for fear of saying the outrageous.

“At least describe what you see,” I said, trying to instil some confidence.

“There is a fleshy-looking soft tissue lesion around the right orbit pushing onto the eyeball. It seems to have eroded the lateral wall of the orbit and a bit of the base of the skull, infiltrating the temporalis muscle as well,” he muttered, albeit correctly.

“So, what could it be?”

Once again, a couple of blank looks were exchanged, all in the presence of the patient who was nauseous with anticipation, eager to know what was going on inside her.

“Looks like a tumour to me,” he concluded sanguinely. Another doctor suggested that it could be a deposit from a lymphoma. The others ricocheted that it could be something inflammatory. “Anyone for infection—bacterial, fungal, tuberculosis?” I asked. They all nodded—some meekly, others mindfully.

Tuberculosis or TB should always be considered in atypical-looking lesions of the brain; the correct diagnosis comes from recognising patterns and keeping an encyclopaedia of possibilities open. Most people associate TB as being a problem of the lungs, but TB can affect any organ that has a blood supply: the brain, spine, skin, muscle, bone, intestine, liver, kidney, spleen, and even the heart; everything except the nails, hair, and teeth. Given the endemic nature of this disease in our country, it always makes the list of differentials.

There was a time when TB or one of its manifestations or complications could pass off as an answer to any question asked in an exam. Data suggests that two to three thousand people die of TB daily in India, because the bacterium is becoming resistant to the first line of drugs available to treat it. There was also a time when many of the uncertain or unexplained lesions in the brain and spine were empirically treated with anti-tuberculosis drugs and a vast majority would heal; that’s how we differentiated many ghoulish cancers from a certainly curable diagnosis of TB. But in today’s practice of medicine, almost every suspicion of the diagnosis of TB needs a biopsy to prove the same and document drug sensitivity.

I explained to Mrs Gandhi the possibilities of this being a tumour or infection, mostly TB. We would have to do an intraoperative histopathological analysis or a “frozen section” of the tissue to decide on a further course of action. If the pathology of the mass during surgery suggested the presence of a tumour, we would attempt to remove it extensively. If it suggested TB, we would remove only enough to relieve the pressure on the eye without risking damage to neurological function, as post-operative anti-TB medication taken for a year would wipe out the residue effectually.

The next day, we did a craniotomy and removed most of the tissue as we waited for an answer from the pathologist, who was scrutinising the cells under a microscope in a lab nearby. Sometimes, even pathologists may have a portentous time differentiating one condition from the other depending on the tissue they receive.

I once remember operating on a brain tumour in a HIV-positive patient. The scan looked like a lymphoma—a tumour that melts with a single dose of steroids and then some chemotherapy. We had decided, owing to the precarious location of the tumour deep inside the brain, that if the frozen section showed a lymphoma, we would not remove it completely, but that if it were any other tumour, we would go after it. The pathologist decreed it to be a lymphoma and so we stopped. The next day, despite high doses of steroids, the patient had malignant brain swelling and died. A few days later, while carrying out assiduous testing, the pathologist entertained the possibility that the cells showed a high-grade brain cancer also known as glioblastoma. He was apoplectic that some of those cells had mimicked a lymphoma. I was devastated.

While we waited for the report to come in on Mrs Gandhi, we casually bet a coffee as we removed more abnormal tissue from her head. “This looks like tumour to me,” I said, giving my final remarks. My assistant disagreed. “It’s TB,” he announced, and he was right. We finished the job and a few days later gave her the positive news that her TB was sensitive to the first line of drugs. She was back to work in a week, the scar perfectly covered behind her hairline; no one in the office could tell she had just had brain surgery. A year later, she was cured, a scan showing no trace of the lesions.

Medicine focuses on discerning the original and discarding the mimic. The word “diagnosis” arises from the Greek “to know apart”. A severe bout of gastritis can mimic a heart attack, and that of low blood sugar can imitate a stroke. A complex migraine can present itself in the same way as does a brain haemorrhage. A simple lump can be camouflaged as cancer. In our present times, a regular cough and cold masquerades as COVID.

If human beings at their very core are not true to themselves, how do we expect our illnesses to be? Or not to be.

14 Comments on “TB or not TB
  • Supriya says:

    The fabulous Dr Turel!! Always awesome,keep rocking!!!

    Reply
  • Avinash Karnik says:

    You have taken the trouble to explain to the general public like me the process or differentiate the opinions of doctors around you and arrive at the final diagnosis. A critical Analysis on which the critical surgery would depend.
    Your flare of writing in simple language for the readers is simply outstanding. Keep up the good work and arrive at right decisions that would make the difference between life and death for the patients. God bless you with added ability to analyse and save many more lives under your knife

    Reply
  • Mayur says:

    Very nicely explained and the efforts taken by the doc for his patient. Which is very tocuhing and humane.

    Reply
  • Arun Pushkarna says:

    At 66 I have learnt for the first time that TB can attack the brain, heart etc. To think that at one stage I thought a career in medicine would be a nice way to spend the rest of my working life..!!
    Thank you Mazda. Your writings inform, entertain, illuminate and inspire.
    God bless you.

    Reply
  • Chandan Sanjana says:

    Very very informative. So much depends too on the report of the pathologists findings. The tensions that the patients and their families go through is terrible, same tensions as the doctors go through to provide the patients with the correct diagnosis. Everything is so alarming to the layman!

    Reply
  • Dr Shivkumar V Dalvi says:

    A very good writeup about TB of brain n importance of submitting tissue removed for histopath.Particularly,TB can mimic so many dreaded tumours n thanx to effective antiTB medicines TB looks very innocuous n eminently curable.Never give wrong negative vibes to the suffering patient ,in advance.Give him/her a balanced but cheerful view.Very lucidly written, keeping interest n suspense till the end. Dr Mazda shud be congratulated for bringing awareness about such diseases to common people in simple, easy to understand manner.

    Reply
  • Gaurav Lalwani says:

    Thank you Mazda. Very enlightening and really simple yet scientific explanation of how to diagnose correctly and not leave anything to chance.

    Reply
  • Dr Rajesh M Shah says:

    Sir, i really enjoyed reading your articles. I learn a lot from it as well. Today’s topic is actually very common but as you rightly mentioned it is always a challenge for the medical practitioner to come to the final diagnosis. Once again thank you for all your concern about the patient’s betterment.

    Reply
  • Mahashweta Biswas says:

    This was very informative about TB not being associated with only in the lungs. Thanks for explaining this.

    Am glad to know you too go in for team work. Awesome. Very well written & diagnosis explained

    Cheers

    Reply
  • Rita Shirwadkar says:

    Good article ,yes a correct diagnosis very important , very informative write up .

    Reply
  • Zubin Bhesadia says:

    Dear Mazda, this is truly a fantastic read…and very enlightening indeed!!! The way you narrate case scenarios & explain medical terminologies for the non-medical fraternity is stupendous – its like seeing the story unfold in front of your eyes, with great ease in understanding the concepts linked to the cases.

    The article also speaks volumes about your leadership skills, wherein, you invite the junior doctors for their opinions, thereby, encouraging think-tanks, quest for knowledge & feeling of oneness. And you consulting your assistant for his/her opinion during the surgery is also commendable & I’m sure it makes one feel truly valued.

    Would also like to mention here that besides your super-tight consulting & surgical schedules, you still manage to prn such wonderful articles to enlighten the mass at large – clearly showcases your endeavour to spread the knowledge & make the people gain insights into avenues that they didn’t explore or were unaware of while traversing.

    I wish you & the team super success in times to come. Stay safe & be well. More power to you!!!

    Reply
  • Khushroo Patel says:

    As usual your article was very well written and very informative.
    Fond memories of my days in fifties at Grant medical college and makes me very proud that my alma mater produced an excellent Neuro Surgeon who is as daft with his knife as he is with his pen.
    You made the decision to return to India
    Sky is the limit.
    Wish you all the best.
    Like the previous Parsee giants of medicine like Dasturs, your father, Udwadias,Modis, you carry the torch in the 21st century

    Reply
  • Parvin desai says:

    Yes i totally agree with u.In our country T B should always be one of the DD AS IT IS VERY COMMON N CAN PRESENT IN UNUSUAL WAYS.THE QUESTION NOW BEING ASKED IS BIOPSY N EVIDENCE BASD MEDICINE. in the past we would give what was a trial fortnight of anti tb treatment .N most things were solved ,no mri no CT, no biopsy. .

    Reply
  • Farengiz Tirandaz Crawford says:

    Wonderfully explained dear Mazda. So well written. Moreover, I wasn’t aware of the intricacies of TB… being connected to possibly the brain or heart. Thank you for taking the time out and writing such a knowledgeable article in a very interesting form. Way to go!!! Good luck always.

    Reply

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