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Toju’s Curious Case Of Tuberculosis!!! ….Eghosa Imasuen

I was a twenty-six year old doctor, had just finished NYSC and was working in a private hospital near Agboju on the FESTAC axis of Lagos. A mother brought in her son, Toju1 who she complained had not been thriving for the last few months.

Not thriving? If there ever was an understatement, that was it.

Toju was supposed to be sixteen but looked twelve. He had a swollen tummy, a trait that belied the fact that elsewhere he was all bones. He had also been suffering from anorexia (a technical term for loss of appetite; the better known condition mostly suffered by young girls is a psychiatric condition named anorexia nervosa.) Toju suffered from a low-grade fever, something which could only be guessed at from his history of suffering from night sweats, i.e., at around three every morning, he would break out in a profuse sweat, wetting his beddings. He had been to hospital, to church, and his mother had brought him to us because the resident doctors at the teaching hospital were on strike.

When I examined him, I found him to be small for his age; he was skinny, showed signs of recent weight loss, and was at the bottom percentile of weight and height for his age. He was pale. His tummy was indeed bloated, and from my examination full of  fluid; peritoneal fluid, i.e., fluid in the spaces between the intestines.

My diagnostic cap on, I recalled advice I had received from a consultant back in school. We were told that TB was the great imitator. It was more than a lung disease and could take on any form, present as any syndrome. In our peculiar environment—tropical, urban, poor—any odd longstanding illness had to have Tuberculosis as one of its differential diagnoses. So, from the moment I heard that the boy had been “somewhat ill” for upwards of a year, with multiple visits to many hospitals, I feared tuberculosis. Other symptoms that pointed in this direction were the night sweats and the pallor, the anaemia, and the weight loss. But he didn’t have the bloody cough, he didn’t have any cough. That should have taken my mind of TB, you say. Wrong. Tuberculosis usually attacks the lungs but can also affect other parts of the body. It affects the skin, the lymph nodes around the neck causing swellings called scrofula, and the spine, causing a potentially crippling condition called Pott’s Disease. You see, Tuberculosis is an infectious disease caused by various strains of mycobacteria, usually Mycobacterium tuberculosis in humans. It is mostly spread via the air, moving from person to person in coughed-up air droplets and spittle. Mostly, I said. They are odder ways in which it is spread, one being via unpasteurised milk from an infected cow.

I told the mother what I thought he had. She said, that cannot be, Toju is not coughing blood. I said, I know. I will need to take a sample. I produced a needle and syringe, noted the surprise on the mother’s face when I swabbed her child’s belly instead of some vein on his arm and plunged the needle into his tummy. I aspirated some fluid. Immediately I knew that my suspicions had been correct. Even before they were sent to the lab, I knew what the child had. You see the fluid that filled his belly was of a golden hue, the classic straw-coloured peritoneal aspirate. The young man had abdominal tuberculosis.

I sent him for an x-ray, for a skin tuberculin test and for a sputum examination, and sent the aspirate for a microscopic examination (the Ziehl-Neelsen stain) and culture (using the Löwenstein-Jensen media.) Did I wait for the results to come before I began treatment? Of course, not. This is a common misconception; I blame the otherwise laudable campaigns by my colleagues in the medical laboratories. Yes, lab tests are important, invaluable, but they are principally a tool that only doctors are qualified to use; and lab tests were made to aid diagnosis, not be diagnosis in themselves. Your primary concern is the patient in front of you; you can either leave the patient to die and say you were waiting for a lab result, or you can begin treatment. The patient’s response to a line of therapy will also aid your diagnosis. So, I started the young man on first line Anti-TB medication and asked the mother to bring him back in a fortnight for a review of the results of the investigations.

The next time I saw Toju, the change set my heart aglow. It had only been two weeks but his cheeks had already started filling out, the swelling in his belly was down, and there was a spring in his step. I had heard that miracles of therapy came after a correct diagnosis but had never experienced anything this dramatic. The results proved that he had Tuberculosis. I transferred him to the health centre in his local government headquarters to continue DOTS (Directly Observed Therapy, Short Course.) I did not hear from them again—this was in 2003—but I imagine that today, he is healthy, finishing university somewhere, and has a sweet girlfriend that he plans to marry soon.

C’est la vie.

[1] Not his real name

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