MALIGNANT TUBERCULOSIS

Abstract

on and
extensive disease are
the most alarming.5 The
greatest tragedy is the extensive form of the disease
with irreversible structural distortion, fibrosis,
cavitation, bronchiactasis, formation of perilesional
emphysema and total lung destruction.
Extensive
tuberculosis behaves
like malignancy, as
rapidly advancing
illness with wasting,
cachexia and
bleeding
(hemoptysis). It has the penchant to disseminate to
adjacent structures like pleura, lymph nodes or
distant organ systems like bones and brain. Akin to a
malignant lesion, chemotherapy is suboptimal,
surgical intervention is impossible due to extensive
involvement, leading to end stage lung disease with
cor pulmanale, respiratory failure and death.
J Ayub Med Coll Abbottabad 2006;18(3) 2
Pulmonary tuberculosis was romanticized in
the arts and mu sic of the 19th century. The deaths of
Mimi in Puccini's La Boheme and Satine in Moulin
Rouge are portrayed as romantic tragic events.
However, end stage tuberculosis is anything but
glamorous and Mimi and satine exposed everyone
around them to danger with each breath. The dying
faced night sweats, chills and paroxysmal cough,
spreading the disease to other organs of the body,
resulting in the wasting away that led helpless
bystanders to name the disease consumption.
Around 460 BC, Hippocrates identified
phthisis or consumption in late stage as an incurable
disease of his age. Because of that he advised his
followers and students against treating such patients
to avoid damage to their reputation. Yet in the 21st
century it still remains the most devastating dilemma,
where
patients
mostly
young beg
for help
while
physicians
powerlessly
watch them
die.
It is with this milieu that at the time of
diagnosis of Pulmonary
TB, the quantification into
minimal, moderately
advanced with and
without cavitation and far
advanced is imperative.
As treatment with
standard drugs in
disseminated TB,
tuberculous-lymphadentis,
and moderately advanced
with cavitation will not produce a rapid cure, causing
a slowly responding patient to inevitably acquire
irreversible structural damage. It is in this perspective
that early expansion of therapy in moderately
advanced tuberculosis will be a paradigm shift in the
strategy of treating such patients upfront with
effective, and offensive regimen, with a resolve to
cure them and thus save them from end stage
'˜malignant tuberculosis'. If this hypothesis is
perceived correctly it will be an epoch making
change in the final outcome of managing
tuberculosis.
It will truly
reflect the aspirations of
the man who first
discovered
mycobacterium
tuberculosis and
remained the
intellectual forerunner
of tuberculosis control. Such was his fervor for
finding a cure that he finished his Nobel lecture by
reasserting his optimism: The fight has been ignited
fully and the enthusiasm for this goal is so broad that
I am not afraid that it will seize again. If we continue
to work in such a powerful way victory will be
achieved.