25 July 2018

We were certain Malcolm’s symptoms meant cancer – so why were the scans mysteriously clear?

Doctors often get gut instincts about cases; we knew something significant was going on.

A nurse examines patient notes (Photo By Getty)

Annie came and found me when I got back from leave. “I saw your chap – the retired farmer? I went to his house.”

Having not seen a doctor for decades, Malcolm had become a frequent attender of late, his joints seizing up with severe osteoarthritis (OA). But he had never been bad enough to require a home visit. “There are bloods coming back for you,” Annie said. “He’s got cancer somewhere, I’m sure of it.”

I went round as soon as the results were in. Always a lean man, Malcolm looked a little more gaunt. His OA made movements stiff and painful, but he was now so weak that he couldn’t even get up from the chair without assistance.

His daughter had come to help her parents. They sat together on the sofa, listening anxiously while I explained the results: his liver tests were awry; we needed an urgent scan. Like Annie, I was pretty sure we were going to find a liver riddled with metastatic cancer. If so, Malcolm’s prognosis was likely to be a couple of months.

Until we knew for certain, I confined myself to assuring them we’d get to the bottom of things as quickly as we could. It was a great surprise, then, when Malcolm’s abdominal ultrasound was completely normal. Further blood tests showed him to be severely deficient in vitamin D. The biochemists at the hospital felt that could account for the whole clinical picture. We started dosing him with supplements. His liver tests normalised. He felt a little better, but remained unaccountably weak.

Then he developed a cough and wheeze. At last, something to localise the pathology. But a chest X-ray was pristine, and his symptoms cleared with antibiotics. He’d regained enough strength to begin to attend the surgery again, but the short trip exhausted him.

I started to wonder about depression: weight loss and lethargy can be symptoms, and it is a frequent complication of chronic ill-health. I tested the idea with Malcolm and his family: could his OA have dragged him down? They were sure not. But depression can be “masked” – presenting as physical disease – particularly in the elderly.

Annie stuck to her gut instinct: this was cancer, and we were going to need hospital tests to track it down. But which specialty to refer him to? There was nothing to suggest where any tumour might be, and if we picked the wrong consultant that would mean further delays.

In the end, we plumped for gastroscopy – direct inspection of the stomach via a fibre-optic camera – in view of the weight loss. It, too, proved to be clear. Fortunately, the gastroenterologist, wondering whether an occult pancreatic tumour might be responsible instead, got Malcolm straight in for a CT. The scan also took in the lower lung fields, and the radiologist spotted some shadows that hadn’t shown up on the X-ray. The likeliest explanation would be a lymphoma. A type of cancer, but one that might be treatable. Yet the ensuing biopsy was even better news: sarcoidosis.

Sarcoidosis remains a mystery disease, characterised by clumps of inflammatory tissue called granulomas widespread throughout the body. It is probably triggered in susceptible individuals by exposure to an environmental agent such as an infection. At 70, Malcolm was unusual – most patients are young adults, diagnosed on chest X-ray. Mild cases burn themselves out with no intervention. Malcolm’s responded promptly to steroids.

Intriguingly, his joints also improved. Osteoarthritis is common at Malcolm’s age, but sarcoid frequently causes an inflammatory arthritis. I’d assumed he simply had an aggressive variant of OA, but his symptoms actually reflected the superimposed effects of sarcoid.

Doctors often get gut instincts about cases. Fortunately, Annie had been wrong about cancer, but her certainty that something significant was going on led ultimately to Malcolm’s diagnosis and cure.