To be or not to be (TB or not TB)

Tuberculosis is endemic in our country and any one who has fever of unknown origin invariably lands up on anti tubercular drugs. Sometimes patients respond to this empiric treatment and sometimes there is something more sinister lurking around.. We had a middle age gentleman who was in as similar situation. He had fever for six months, had lost weight and was persistently feeling unwell. All antibiotics had been tried and even a course of anti tubercular drugs was given. But fever kept on coming and his inflammatory parameters were raised. When he presented here an echocardiography showed small clumps of possible growth of organisms on his valve. To us this seemed to be the most likely reason for his symptoms. We suggested him to get operated and get his valve changed. As he was fed up of having antibiotics for such a long time he agreed to undergo surgery with lot of reluctance and apprehension.

During surgery, the valve appeared not particularly bad except for the few suspicious areas, which were removed and sent for laboratory examination. He recovered uneventfully his fever subsided and his inflammatory parameters came back normal. Six months later he is a happy relieved man. The cultures from the valve came negative.

Sometimes it is a culture negative endocarditis, which can cause these symptoms, and sometimes it is asterile vegetation which can still continue to cause systemic constitutional symptoms. It is impossible to be sure all the time but yes with lot of experience the chances of getting these things wrong become very low.