Coughing up blood, a dangerous symptom


If I am a diagnostic stud

Whenever a patient coughs blood

     I check for TB

     And cancer, you see.

And I won’t drag my name in the mud.

I won’t say where or when  it happened, but two patients in two days came in because they coughed up blood

I regard one episode of blood from the nose (epistaxis) as normal wear-and-tear, I only do studies if the problem persists, comes from both sides, or occurs in a suspicious context. But blood from the lungs (hemoptysis) tells a different story and always warrants investigation.

The big problems to rule out include cancer and tuberculosis, or TB.

I remember in the 50’s people understood the word tuberculosis; now few do. Caused by a slow-growing relative of leprosy, TB attacks the lungs most often, sometimes the brain, kidneys, reproductive organs, or bone.

Once called “consumption” and all but wiped out by the 70’s, it has returned.  Shortly before my father, an internist, retired, we talked about how TB’s comeback influenced medical decisions.

That discussion happened when I worked in the Indian Health Service.  Native Americans suffer disproportionately from TB; before I finished in the IHS I had served as TB control officer for two different reservations.  Even prior to that, in residency, I saw a patient with lung TB so advanced the infection eroded into the spine, causing collapse of the thoracic vertebrae (Pott’s disease; one of the Pharaohs had it, too). 

Like most other disease-causing germs, TB’s recent resistance to usual drug treatment makes therapy problematic.  I attended a patient whose Korsakoff’s psychosis complicated his multi-drug resistant tuberculosis; his memory permanently impaired, he couldn’t remember three things for five minutes.  To protect the community, he stayed in the hospital ninety days for supervised drug administration.

Some developing countries, including Mexico and Guatemala, address the significant public health problem of TB with BCG, a vaccine which gives limited protection against TB. It impairs the effectiveness of our first-line diagnostic tool, the PPD, injected into forearm skin.  Normal people unexposed to TB will show inflammation less than 5 mm 48 hours after the shot; people with TB will show more than 10 mm, and those who have had the BCG show a less vigorous reaction which cannot be distinguished from TB’s.

 If a patient from outside the US coughs up blood, I asked about tobacco use, get a chest x-ray, and check both shoulders for BCG scar.

I consider cancer as well as TB.  Even though a lung cancer advanced enough to show on a chest x-ray usually has the patient on a fatal course, I still do a chest x-ray.

If a patient who coughs up blood ever smoked (both those patients had), I have to prove that the patient doesn’t have cancer, no matter how the rest of the story goes. 

I made arrangements for both patients to see a  pulmonologist (lung specialist).

A medical malpractice lawsuit named me in a case where a patient coughed up blood from lung cancer and died in a matter of weeks (information in public record) five years after I’d seen him once and told him if he didn’t quit smoking he’d die.  The plaintiff’s attorney dropped my name from the suit two weeks before trial.

Since then I’ve conscientiously arranged for pulmonologist follow-up and chest x-ray on every patient who coughs up blood.

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