A 49-year old lady came in one day complaining of bleeding from her rectum for some weeks. In fact she had just been to see a government out-patient doctor who prescribed her with an anti-fibrolytic (tranxanemic acid) two days earlier and correctly enough she told me that she did not have heavy menstrual bleeding so why should she take that medication? ( she must have asked some people about the drug given to her).
She then related that she had been having haemorrhoid for more than two years and on an on and off treatment by various private doctors. I did inquire about any change of her bowel habit, whether there was a recent weight loss or had her appetite been poor and whether she had any fever. Also whether the stool was hard and the character of the blood whether frank or streaking or mixed with the stool. All the questions were carefully designed to rule out any chronic disease or malignancy. She answered all in the negative. Hmmm......
She was so fashionably dressed in her matching baju kurung (traditional dress) and tudung (a scarf) and appeared healthy and bubbly that I gathered that it must have been a simple haemorrhoid. I then prescribed her an anti-haemorrhoidal preparation plus stool softener and advised her to increase the fibre in her diet. I also told her to reduce the haemorrhoid should it come down after going to the toilet. I did a full blood count (FBC) and found her hemoglobin to be low (10.2 g/dL) and prescribed her iron tablets and other hematinics.
She came again two weeks later and according to the counter staff, she insisted upon seeing me. She waited for over an hour as I had patients on appointment basis. This time she related that blood virtually flowed from her rectum when she stood up from a sitting position. My!... what type of hemorrhoid was this? As I did not have a proctoscope to really look at the rectum satisfactorily, I decided to refer her to a general hospital surgeon.
Ten days later she returned to my clinic with the report of the lower gut biopsy and the surgeon's proctoscopy report. The tissue showed changes consistent with tuberculosis infection! I nearly jumped out of my chair! Immediately I ordered for her chest to be x-rayed and oh my God!, There it was.... full blown pulmonary TB with spread to the gut! Looking ominously infectious. We missed this diagnosis simply because she did not complain of any respiratory symptoms. Her sputum Acid Fast Bacilli (AFB)- TB germs was 3+ on the first sample! I was flabbergasted. After all my nurse and I had already stopped wearing our surgical masks since the H1N1 virus pandemic had been called off....and just how many people had she infected before being finally diagnosed!
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| Chest X-Ray of the patient presented with rectal bleeding. The consolidation is generalised especially on the right lung and both apical spaces, akin to milliary TB (photo taken by Sony DSC-TX7) |
The unfortunate woman was duly put on an anti-TB treatment and all her contacts traced and tested.
A few days after this worrisome episode, a young and petite 21 year old female college student came complaining of recurrent coughs and chest pain radiating to the back ( we were already wearing our mask this time). She had been to a district hospital several times and was repeatedly treated for respiratory tract infections with several courses of antibiotics. She came to the city, thinking that our clinic had better facilities for diagnosis because her condition had worsened.
She insisted that her cough had only been for one week this time! However, being over-cautious then, I asked her whether any of her family member had had TB, she answered "yes" her maternal grandmother had TB. Without wasting any more time I ordered for a chest X-ray and sure enough, staring right in front of me was the beautiful "Ghon focus" a classic sign of TB infection of the lung. How could the district hospital staff have missed it! Simple, they did not have a high index of suspicion and that they did not ask the right questions. This patient could also have infected others especially those in close contact with her. They must be traced and screened.
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| Chest X-ray of the 21 year old patient. Note the Ghon focus (circular cavity) surrounded by consolidation, on the upper right lung. The left lung is relatively clear. (photo taken by Nokia E7 |
I did not diagnose any TB cases last year but here they were, two in the space of one week! And in different guises as well... this is an occupational hazard which I must not take for granted.
I hope doctors are more aware of this infectious disease especially with the rise of HIV cases in the world. HIV-infected individuals are immuno-compromised and they are more susceptible to infection by TB germs. We need to detect them early to reduce transmission in the community.
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