Thrill during diagnosis

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It gives us immense pleasure to be in a hospital. We always get thrilled when we recall that we belong to the medical field.

One working day, when we were in OPD, a middle-aged man entered the room and proudly introduced himself as a farmer. The man, probably in his mid-50s, had to work hard to earn bread and butter for his family. As I asked his medical problem, he complained of having intermittent flank pain for quite some time. He told us that the pain, sometimes, would be so bad restricting him to give his best on the farm

When asked further about any other problems, he denied having fever, backache, or other discomforts. As per the medical protocol, medical examinations of the patient were carried out. Everything was in a normal range.

As he was experiencing discomfort and test results were normal, he had to undergo some additional testing to diagnose the disease. We recommended him for an ultrasound test—but he could not get it done on time. The farmer did not have relatives or friends in the hospital to get his test done. It is a harsh reality, but nepotism and favoritism is more rampant in Nepal.

As only limited tests were carried out, directly jumping for a diagnosis was not an easy task. But, being a medical professionals, we could guess the disease through symptoms. Was it stones in kidneys? Or infected kidneys?

Wouldn’t you expect fever, positive family history, history of weight loss, palpable nodes, aches in joints, and tenderness in renal angle if it was the case of infected kidneys? But looking at the profession of the patient and symptoms, considering his case as kidney stones was a plausible explanation.

The patient was a farmer. He barely could have time even to drink a glass of water. Regular dehydration increases the chances of crystal formation in kidneys. Also, kidney stone is a common problem in Nepal.

As it could be a possible case of kidney stone, we did not want him to wait for testing in a government hospital. We recommended him to get his scan done from a private hospital as it was beyond my capacity to schedule testing in our hospital within a few days.

The old man agreed to my request. He performed his test from a private hospital. The test report was out the same day. But to my surprise, there were no stones in the kidneys.

We were in a big surprise. We did not expect that sort of report. Then, I looked at the name of the radiologist as everyone does when the expectations don’t meet. He was an eminent radiologist. We weren’t satisfied with the flow of the case. We told him that his basic reports didn’t reveal any abnormalities. What would be your next step? Send him home with analgesics? Convince for new investigations?

He was not in a state to undergo any more investigations, neither mentally nor financially. But we convinced him to come for a follow-up in a month.

When he came for a follow-up, he complained of repeated pain on the flanks at times, which subsided with antispasmodics. I requested him to get an ultrasound of the abdomen and urine routine again. What do you think it revealed?

He had swelling of the kidneys on both sides, which is labelled as hydronephrosis. In fact, it is dilation of a pelvicalyceal system rather than enlarged kidneys. We thought there must be some obstruction to swell them up. So, we convinced him to get the CT scan done. It didn’t add to the diagnosis. There was no obvious obstruction with stones or tumors.

Before the CT scan report, we thought the ultrasound couldn’t find stones in gray area of the urogenital tract, lower ureter. What do you think now? There is no obstruction? But there was. He had derangement in renal function as well. His serum creatinine was 1.7 mg/dl, which was 0.5 mg/dl higher than the first time. His urine was bland.

We expected RBC in urine if it were stones or luminal culprit. However, it is not hard and fast rule. So, what do you do now?

Suppose the patient had a hemoglobin of around 8 mg/dl, with a history of loss of appetite and unconfirmed weight loss for months. What would you do then? You insert scopes to find out the loss. To your expectation, you found cancer stomach, proven on biopsy few days later. The possibility of the tumor seeding to ureters and encasing them to cause obstruction would be a likely explanation. But such was not the case in this poor farmer. He didn’t have abnormal lab tests. It wouldn’t be logical to search the tumors in his body just to satisfy thirst for diagnosis.

We decided to consult the CT scan report again. On discussion with the radiologist, he looked for possible problems in the urogenital tract and its vicinity. He had retroperitoneal fibrosis, which was initially ignored. So what?

We sent IgG4 levels in the blood and asked the radiologist to take a biopsy from the mass behind the retroperitoneum. The biopsy was especially ordered for IgG4 Staining. The pathology report came positive with a description of storiform fibrosis. What do you do now? Steroids and methotrexate for poor people. There is always Rituximab for the prosperous ones.