7. The Biopsy

 

Monday morning, a new week was starting. I grabbed a snack from the gas station and ran to the subway at 6am. I was still looking for a roommate after Jax got married, and preferably one that did the groceries like he used to. I was getting tired of eating cold snacks in the morning.

‘Good morning, Linda!’ I said to our receptionist when I got to the clinic.

‘Hi, Lisa.’ She smiled. ‘You are terribly early as usual.’

I shrugged. ‘Bad habit.’ And she laughed.

I went to my office and began going through some charts. Eventually, patients got there and we started our work. Sarah Bell was a 40-year-old black woman. She got to our outpatient clinic an hour late for her appointment. Usually that means you lost it, go home and reschedule it. But that day she insisted with our receptionist she was so sorry for the delay so Linda said she would try her best then came to talk to me. We went over my schedule and I told her I would see Mrs. Bell after my last morning patient.

‘Good morning, Mrs. Bell.’ I told her as she was getting into my office.

‘Good morning, Dr. Diaz. I am so sorry I was so late, thank you for agreeing to see me.’

I nodded. 'That's okay. How can I help you today?’

‘Well, I came to show you my x-ray.’

She handed me a chest x-ray that just by glancing at it I could see there was something wrong with it.

‘I see.’ I said taking her x-ray and putting it on my table. ‘I am gonna take a look at it in a moment, but first, let’s start from the beginning. What’s happening to you? Why did you get this x-ray?’

‘Oh, sure. It’s the cough. I’ve been having an annoying cough for a year now. I tried everything you can think of, syrups, pills, even tea. So I saw a doctor, I don’t remember his name, who asked me to get an x-ray.’

I checked her chart but didn’t find any notes on that previous appointment. I asked some follow-up questions and found out that it was a dry cough, she didn’t think it was worse in any particular time of the day, and she had no other upper airway symptoms. However, she did have occasional fevers, shortness of breath and weight loss. A few red-flags were popping in my mind by then.

She didn’t smoke or drink and had no previous health conditions. I thoroughly went through her review of systems, but nothing came up.

I excused myself from the room to look at her x-ray. Like I had seen on my rapid glance, there was an evident bilateral hilar adenopathy. TB came to mind. It would explain her cough, x-ray, fevers and weight loss after all.

I came back to the room and it occured me to ask her if she had any other exams with her.

‘I think I have some blood tests as well.’ She answered as she went through some papers in her bag and handed me an envelope.

There were some basic tests all within normal ranges, but one abnormal lab which was a high calcium. I mentally added lung cancer to the list. I proceeded to her physical and everything seemed to be normal until I got to her legs.

‘What about these, Mrs. Bell?’ I pointed to some lesions on her shins.

‘Oh, yeah.’ She said sitting up and looking at her shins. ‘I forgot about them. It comes and goes, sometimes they get a little sore.’

I left the room once again to discuss her case with Dr. Rivers. He nodded while I walked him through her cough, constitutional symptoms, high calcium, suggestive x-ray, shin lesions.

‘Erythema nodosum?’ He asked.

‘Exactly!’ I answered wondering how I have not thought of that.

He nodded. ‘Go on.’

I finished with my thoughts on lung cancer and TB and what I thought we should do next.

‘You have good hypotheses, Dr. Diaz. But there’s one more possibility for her that you can’t forget.’

I scratched my head looking for the answer.

‘We will scan her like you said.’ He started. ‘And we will probably go for the biopsy. What can we see in the biopsy?’

‘Well, it depends. It can show malignant activity if it is cancer. Caseous necrosis if it’s TB.’ I suddenly clicked. ‘And non-caseating granulomas if it’s Sarcoidosis!’

Dr. Rivers smiled. ‘That’s what I wanted.’

I went back to the office and explained to Sarah what we thought it could be going on with her and how her investigation would go on. A few weeks later I learned that her biopsy indeed had shown the noncaseating granulomas of Sarcoidosis and she was started on steroids.

I got home that day thinking of how I should have thought of Sarcoidosis sooner. I went over everything I thought should have done differently over and over again in my head until I was completely exhausted. Starving, I opened the fridge to find only empty shelves.

I sighed.

Yep, I needed a new roommate.

...

Want to know more about Sarcoidosis?

https://www.amboss.com/us/knowledge/Sarcoidosis/

Want to read a real case of Sarcoidosis?

https://casereports.bmj.com/content/12/3/e227929

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