A 55 year old woman comes in disoriented from severe dehydration: she's been urinating too much, and complaining of excessive thirst for about a week. She's also complaining of burning sensation in her tummy, and is vomiting something the color of coffee: altered blood probably. Before these, she's been losing weight, sweating a lot at night, and coughing out blood occasionally, for about 3 months.
Pulmonary tuberculosis, you think. She probably had diabetes, with poor sugar control, which weakened her immune system, leading to her developing of TB. The TB, in turn, as a major metabolic stressor, must have worsened her poor blood sugar control, leading to excessive urination, and dehydration. An urgent random blood sugar confirms this theory, to an extent-- or so you think.
The heartburn, and coffee-ground hematemesis? Probably a gastritis, or ulcer, from a variety of possible causes, notably NSAID abuse-- a common thing in these parts, since the locals are mostly farmers, and usually abuse pain medications to relieve body pains.
First things first: you aim to rehydrate her, have her blood sugar under control, control the ulcer symptoms, and place her on antibiotics, while you wait for confirmatory investigations.
By the following morning, she's feeling much better: she is no longer disoriented, heartburn and vomiting has subsided, and she is even able to sit up by herself without any support!
Now you're seeing her more clearly -- thanks to daylight, and the fact that she can now sit up; and you notice some other features suggesting a different diagnosis that would explain all her problems better. She has massive accumulation of fat above her shoulders, and behind the back of her neck-- all looking like the hump of a Buffalo; her face is plethoric; limbs are thin relative to her unusually protuberant tummy; there are horrible stretch marks on her tummy; she's having waist pain; and she has been having recurrent ankle swelling for about 3 months!
The picture is screaming one thing: Cushing's syndrome -- a condition in which there's high levels of a hormone called cortisol in the system, leading to abnormalities such as: rise in blood glucose level, and an ulcer-like condition-- both in addition to the aforementioned signs seen in the index patient.
There are dark pigmentations in the patients palm, lips, and skin creases. With this additional feature, you know that the cause of her own Cushing's is unlikely direct increase in corticosteroids, from an exogenous source, or from an endogenous source; that it is most likely due to high levels of ACTH, a hormone that, when in excess, both raises levels of corticosteroids in the body [leading to Cushing's], and increases expression of melanin-binding protein [leading to increased pigmentation of the skin].
Instinctively, you know that that cough isn't TB anymore; it has to be something more sinister. And 2 hours later, the Gene Xpert result proves you right: Mycobacterium tuberculosis not detected!
Diagnosis? The woman most likely has a type of lung cancer called small-cell carcinoma, which in addition to causing chronic cough with hemoptysis [coughing up blood], could also elaborate high levels of ACTH leading to Cushing's syndrome. Beautiful pathology!
The beauty of medicine lies in outwitting cunning, and devious Pathologies; it gives the average doctor a considerable high of euphoric proportions. Unfortunately, the doctor's "intellectual high," is the patient's worse nightmare.
Aren't we a bunch of sadistic freaks?
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