In Boston, I often see patients bounced around from one hospital or specialist to another. It is a bit surprising to see this
Large pleural effusion on ultrasound
happen here in Achham, where the main challenge is a dearth of clinicians and hospitals, rather than an excess of them. A sixty year old woman had been sick for several months with cough and shortness of breath when she initially came to our hospital. While here, a chest x-ray was read as pneumonia and she was treated with antibiotics. A month or so later, not feeling better, she went to the district hospital a few hours away where she was found to have a pleural effusion (fluid around her lungs). Some fluid was removed for basic analysis, no clear cause found, and she was referred to a hospital over fifteen hours away where a more extensive workup was performed. Ultimately, she was diagnosed with tuberculosis and prescribed anti-tuberculosis medications, despite the fact that the hand-written, disorganized papers she was carrying in a plastic bag seemed to indicate a concern for malignancy and her tuberculosis tests had come back negative. Her son explained, however, that upon discharge from the hospital two months later, they never received any anti-tuberculosis medications or follow-up. She carried with her a small copy of her chest x-ray, and it looked similar, though less severe, to the one we did: a large pleural effusion, although now the effusion was so large that her heart was pushed over to the right side of her chest by the fluid. She was so short of breath that
Microscopy of the pleural fluid.
we were concerned that she would collapse. We elected to repeat the thoracentesis (fluid sample from the chest), and our Health Assistant Chanakya Timilsina performed it, drawing out 1.5 liters of fluid while using ultrasound to guide us. The patient felt symptomatically better. It was late at night, and our Lab Assistant Rajendra Dhami performed microscopy, conducting three AFB (tuberculosis microscopy) tests, and a protein analysis on her samples. The tests were suggestive of malignancy versus tuberculosis, but most strongly of tuberculosis (lymphocytes in the pleural fluid, high protein). We would aim to get sputum as well, but would start her on anti-tuberculosis therapy in the morning, as long as she was stable.
So here we are. At least seven months since the start of symptoms, through three hospitals, and only now would she get any sort of potentially curative treatment. Her condition is incredibly tenuous and I don’t think she will survive. While I hope we can help her, I’m fairly certain at this juncture, it was far too little (coordination and follow-up), too late.
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Duncan Maru, MD, PhD is the co-founder of Nyaya Health. He is currently a resident in the Internal Medicine – Pediatrics program and fellow in Global Health Equity at Brigham and Women’s Hospital and Children’s Hospital of Boston.
