“Dr. Rahman, can you squeeze in this patient today, she has kidney mass and is having fevers, and they really want to be seen today by you?”
Already facing a full day, I advised my triage nurse that if the patient could be in the office before 4:30 I would see her. She obliged and the patient was double booked into my schedule. As the end of the work day approached and Mrs. R checked into my office to be seen, I started reviewing her records from a recent hospitalization. She was running fevers when she was admitted to the hospital where a CT scan and MRI demonstrated a cystic mass in her right kidney. The mass was thought to be a cancerous. The infectious disease physician and oncologist both felt that the underlying cancer was the source of her ongoing fevers, and ultimately discharged her with hopes that removal of her kidney by a urologist would cure both her cancer and fever.
Armed with this information, I went to see an ill-appearing 71 year old woman of Indian descent, who was literally 20 days older than my mother, accompanied by her son who was about my age. They had travelled nearly 45 minutes to see me, mother looking ill and son very worried. She had travelled to India nearly 6 weeks prior and had started suffering from burning upon urination, fevers and gross hematuria. While there she was started on Levaquin antibiotic for a urine infection, and renal ultrasound was obtained which showed cysts in her kidneys. She improved slightly, enough to travel back home to NY, but still was having chills and fevers upon arrival. She saw her primary care doctor who was concerned enough to admit her to the hospital for a workup.
After hearing her story and examining her, I stepped out of the room to review her films online. “How could a story that started out as an infection turn into a patient with cancer?” was went through my head. Certainly kidney cancer has a reputation of being “the internist cancer” as it could potentially present as a number of systemic clinical complaints, but this story wasn’t consistent with anything that I had seen in my experience with kidney cancer patients over my career.
I reviewed the films from both the MRI and CT scan, and I thought that “the cystic neoplasm” with its fluid-filled septations could easily be an abscess, or pus-filled infection, in the right clinical scenario. It dawned on me as I went back in to talk to my patient that this was that clinical situation!
I explained to the patient and her son that I did not think that the cancer diagnosis was correct, and that I was more concerned that this was a kidney abscess causing her fevers. I got her directly admitted to the hospital, reviewed her films with the interventional radiologist at my hospital who agreed with my interpretation, started her on IV antibiotics, and planned to have a drain placed in the kidney to remove the pus the following morning. The family was optimistic but still had lingering concerns regarding a cancer diagnosis. The following morning, a drain was placed in her kidney and 25 cc of pus was removed from her kidney, confirming my diagnosis. The family was greatly relieved, and over the next week in the hospital she stopped having fevers and slowly made a full recovery.
Although I spend a lot of time delivering a cancer diagnosis to patients and their families, the thrill of refuting a cancer diagnosis and offering relief and hope to a family while improving their condition was exhilarating for both the patient and me.