Chandra's corner - November 2018

Dr PH Chandrasekar

"Youth is wasted on the young"
- Bernard Shaw

A landmark: fifty years since I joined the Christian Medical College, Vellore. To celebrate, reunite, reminisce, grateful to be alive and intact, I returned home to Vellore in August. The thought of encountering my “old” classmates, after forty plus years, ignited joy mixed with anxiety and trepidation. I was not sure what to expect. Happily, the entire event was memorable; everyone had a friendly smile, caught up on stories, but just not enough time. It was striking to realize people were just the same-growing old simply does not alter people. Almost everyone’s behavior was the way I remembered and was quite predictable; that was somewhat disappointing. Our batch had chosen an apt song for the entertainment portion of the evening. I liked it, so would like to share a part of the lyrics. This should strike a chord in at least a few of you as it surely did in me.

Enjoy yourself, it's later than you think
Enjoy yourself, while you're still in the pink
The years go by, as quickly as a wink
Enjoy yourself, enjoy yourself, it's later than you think
You're gonna take that ocean trip, no matter, come what may
You've got your reservations made, but you just can't get away
Next year for sure, you'll see the world, you'll really get around
But how far can you travel when you're six feet underground?
You work and work for years and years, you're always on the go
You never take a minute off, too busy makin' dough
Someday, you say, you'll have your fun, when you're a millionaire
Imagine all the fun you'll have in your old rockin' chair
Enjoy yourself, it's later than you think
Enjoy yourself, while you're still in the pink
The years go by, as quickly as a wink
Enjoy yourself, enjoy yourself, it's later than you think

From Vellore, after a brief stop in Chennai, I went to Hyderabad to attend the Annual Transplant Infectious Diseases Meeting. The audience size was modest, the content however was good. One of the case management sessions left a ‘teaching message’ in me. A renal transplant recipient with fever, acute breathlessness and pulmonary infiltrates was admitted to the intensive care unit. During the management discussion, a discussant (a non-ID physician) proceeded to give rationale for combined empiric therapy against tuberculosis, MDR Gram-negative pneumonia and pneumocystosis, totaling about ten drugs including corticosteroids. Not surprisingly, “just in case” was the argument presented for the steroid-inflated regimen. It is true that empiric therapy often is lifesaving, particularly in the intensive care unit, but the pragmatic ID physician, in such cases, prioritizes, uses clinical judgment, provides careful stewardship and prescribes drugs with sound rationale. This ingredient of clinical judgment is that which distinguishes the ID specialist from others. The discussion we had around the case highlighted the desperate need for good, clinical ID physicians in India. Appropriate use of antibiotics is crucial such that their precious lifespan may be prolonged. This point came across loud and clear during the case discussion, leaving me somewhat relieved with a broad smile on my face.

A few weeks ago, I saw a HIV-infected, non-adherent patient with swelling and a deep tender ulcer of his lower lip, along with impressive, painful enlargement of lymph nodes (‘bubo”) over his left neck. HSV was ruled out; persistent exam/testing ultimately confirmed a diagnosis of Lymphogranuloma venereum (LGV). PCR from the lip ulcer was positive for LGV, and his throat swab revealed for chlamydia. Therapy with doxycycline led to dramatic improvement. LGV orolabialis with cervical lymphadenitis was a new one for me; literature search revealed nothing. As sexual mores change, newer/unusual clinical presentations become the norm. Keep up with the times, lest you’ll be left behind, as text books are re-written!