Tuesday, November 25, 2008
As I have previously mentioned, in medicine we try and formulate a differential diagnosis as we are seeing patients. We are trying to think in our minds all the things this pt could possibly have and by asking questions, getting labs, Xrays, etc, we are ruling in or ruling out some of these diagnoses. For most patients that I see, my differential includes things that are most common and things I have some knowledge about. At other times, I have gone through everything in my differential and nothing has proven to be correct, so then I ask Bill for his help. He has been doing this a lot longer than me, so his differentials often include things I have never heard of nor seen before, which is why they didn't enter my differential. The other day I walked into his clinic room to ask him a question about my patient, but instead he asks me about his patient and what I think. Leprosy is something I have never seen before, but read about (in the Bible). I knew very little actual medical knowledge about leprosy until this week and this patient. We haven't had a new leprosy case here in quite a few yrs, which was evident when Bill was trying to find medicine for him and we found we don't have it. So for those of you who might not know much about leprosy, let me explain a little from my reading. It is caused by Mycobacterium leprae, and despite how leprosy is often depicted, it isn't as contagious as was previously thought. It typically is spread from nasal secretions of the infected getting into others nose or mouth. Direct skin contact will not pass along the bacteria. The incubation period is 6 months to 40 yrs, so it often is quite a while before someone who was infected by another shows any signs of illness. Lepromatous, tuberculoid, and borderline are the 3 different kinds of leprosy. Leprosy affects the peripheral nerves and skin mostly, and tends to like the cooler parts of the body. As a result pts can't often feel things and get ulcers or infections on their hands or feet. They also can lose the function of their nerves, get muscle atrophy, or deformities as a result. When it affects the skin they often have areas of hypopigmentation where they can't feel anything, or get lots of bumps on their skin. After cutting the pt's earlobe (cool spot) and getting some fluid for the lab to look at, Bill determined his pt has lepromatous leprosy. He does have some bumps of his face and other skin changes, and has lost his lateral eyebrows. Thankfully, he doesn't have much nerve damage presently and are hoping that won't change with the medicines (when we get them). The antibiotics we will give him will stop the progression of the disease, but can't reverse what has already been done. So after this patient, leprosy can now enter my differential as I have seen someone with it and know a little something about it too. This case illustrates for me why I am so thankful to be here. I have learned so much since I have been here because I have seen so many things I had only read or heard about. I am especially thankful to have a good teacher in Bill, who has taught me so much. He just had a birthday so he is getting older, but all those years add up to a lot of wisdom and experience to share and I have learned a lot as a result. Thanks Bill.