Abstracton andextensive disease arethe most alarming.5 Thegreatest tragedy is the extensive form of the diseasewith irreversible structural distortion, fibrosis,cavitation, bronchiactasis, formation of perilesionalemphysema and total lung destruction.Extensivetuberculosis behaveslike malignancy, asrapidly advancingillness with wasting,cachexia andbleeding(hemoptysis). It has the penchant to disseminate toadjacent structures like pleura, lymph nodes ordistant organ systems like bones and brain. Akin to amalignant lesion, chemotherapy is suboptimal,surgical intervention is impossible due to extensiveinvolvement, leading to end stage lung disease withcor pulmanale, respiratory failure and death.J Ayub Med Coll Abbottabad 2006;18(3) 2Pulmonary tuberculosis was romanticized inthe arts and mu sic of the 19th century. The deaths ofMimi in Puccini’s La Boheme and Satine in MoulinRouge are portrayed as romantic tragic events.However, end stage tuberculosis is anything butglamorous and Mimi and satine exposed everyonearound them to danger with each breath. The dyingfaced night sweats, chills and paroxysmal cough,spreading the disease to other organs of the body,resulting in the wasting away that led helplessbystanders to name the disease consumption.Around 460 BC, Hippocrates identifiedphthisis or consumption in late stage as an incurabledisease of his age. Because of that he advised hisfollowers and students against treating such patientsto avoid damage to their reputation. Yet in the 21stcentury it still remains the most devastating dilemma,wherepatientsmostlyyoung begfor helpwhilephysicianspowerlesslywatch themdie.It is with this milieu that at the time ofdiagnosis of PulmonaryTB, the quantification intominimal, moderatelyadvanced with andwithout cavitation and faradvanced is imperative.As treatment withstandard drugs indisseminated TB,tuberculous-lymphadentis,and moderately advancedwith cavitation will not produce a rapid cure, causinga slowly responding patient to inevitably acquireirreversible structural damage. It is in this perspectivethat early expansion of therapy in moderatelyadvanced tuberculosis will be a paradigm shift in thestrategy of treating such patients upfront witheffective, and offensive regimen, with a resolve tocure them and thus save them from end stage‘malignant tuberculosis’. If this hypothesis isperceived correctly it will be an epoch makingchange in the final outcome of managingtuberculosis.It will trulyreflect the aspirations ofthe man who firstdiscoveredmycobacteriumtuberculosis andremained theintellectual forerunnerof tuberculosis control. Such was his fervor forfinding a cure that he finished his Nobel lecture byreasserting his optimism: “The fight has been ignitedfully and the enthusiasm for this goal is so broad thatI am not afraid that it will seize again. If we continueto work in such a powerful way victory will beachieved”.
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