THIS IS AN ONLINE E LOG BOOK TO DISCUSS OUR PATIENT'S DE-IDENTIFIED HEALTH DATA SHARED AFTER TAKING HER SIGNED INFORMED CONSENT. HERE WE DISCUSS OUR PATIENT'S PROBLEMS THROUGH SERIES OF INPUTS FROM AVAILABLE GLOBAL ONLINE COMMUNITY EXPERTS WITH AN AIM TO SOLVE THOSE PATIENT'S CLINICAL PROBLEMS WITH COLLECTIVE CURRENT BEST EVIDENCE BASED INPUTS.
[8:07 am, 09/04/2026] PA: Mam patient has fever since 6 months but not continuously. Suffering from fever last 20 days regularly and has cough since 2 months and suffering from food digestion vomiting sensation and motions
[8:08 am, 09/04/2026] PA: Akali avuthundhi but she can't take complete food due to vomiting sensation
[8:50 am, 09/04/2026] PPM 1: Please protect your patient's privacy by not sharing her identity online.
[8:50 am, 09/04/2026] PPM 1: Please protect your patient's privacy by not sharing her identity online.
The chest X-ray is very much suggestive of left upper lobe tuberculosis.
We need to start your patient on antitubercular therapy ASAP.
Please share the report of her sputum AFB so that she can be started on free treatment from her nearest primary health centre free of cost.
[9:52 am, 09/04/2026] PPM 1: This may provide temporary relief but she will need definitive therapy for her pulmonary tuberculosis ASAP after her sputum AFB and CBNAAT
[11:06 am, 09/04/2026] PPM 2: Can I see the CXR here please?
[1:37 pm, 09/04/2026] PA: Patient reported these tests tomorrow doctor
[3:29 pm, 09/04/2026] PPM 2: Lung collapse is evident here. @PPM1 Sir Koch's?
[4:03 pm, 09/04/2026] PPM 1: Yes
[4:05 pm, 09/04/2026] PPM 1: Yes but we need to see the report of her sputum for AFB and CBNAAT. @PPM3 was that done yesterday?
[4:10 pm, 09/04/2026] PPM 3: Sir, they said that they will get done the test tomorrow at Govt. Hospital
[4:12 pm, 09/04/2026] PPM 4: There is mediastinal shift to left. And LLL airspace consolidated and maybe L left sided effusion. Is there pneumothorax also on the right side? I can't make our bronvhiavascular markings on the right.
[4:12 pm, 09/04/2026] PPM 2: Agreed and I thought the same too and then zoomed in and saw some bronchovascular markings on the right in the lower zone
[4:15 pm, 09/04/2026] PPM 4: That would make sense because the trachea appears midline. Maybe simply an overexposed film makes the right lung so dark.
[4:17 pm, 09/04/2026] PPM 1: And this is a rotated film as you can see the right clavicular head is on the cervical spine while the left clavicular head has shifted further from the centre.
[4:17 pm, 09/04/2026] PPM 1: Yes! The intervertebral discs are a bit too prominent and likely from overexposure.
[4:16 pm, 10/04/2026] PPM 1: 👆@PaJR Health can you tell us what the numbers CT 26.33 and mtb 22 mean and their role in deciding mtb positivity vs negativity in the sputum?
[4:18 pm, 10/04/2026] PaJR Health: *CT 26.33 AND MTB 22 IN Xpert MTB/RIF INTERPRETATION*
*CT (Cycle Threshold) 26.33:* This is the cycle number at which the PCR amplification curve crosses the detection threshold. Lower CT values indicate higher bacterial load.
*MTB 22:* This refers to the CT value specifically for the Mycobacterium tuberculosis (MTB) detection probe. In Xpert MTB/RIF, there are multiple probes: MTB (for detection), rpoB (for rifampicin resistance), and internal control.
*CLINICAL INTERPRETATION:*
1. *MTB Positivity:* Any CT value ≤38 for the MTB probe indicates MTB detection (positive result). CT 22 is well within the positive range.
2. *Bacterial Load Quantification:*
- CT 22 indicates *moderate to high bacillary load*
- Lower CT = Higher bacterial load (more infectious)
- CT 26.33 (if from another probe or average) aligns with this moderate-high load
3. *Correlation with Smear Microscopy:*
-20: Usually smear-positive (high bacillary load)
- CT 20-28: Often smear-positive or scanty positive
- CT >28: More likely smear-negative
4. *Infectiousness Prediction:* CT values correlate with smear grade and infectiousness. CT 22 suggests significant infectious potential.
*EVIDENCE FROM RECENT STUDY:*
A 2025 multicenter study (PMID: 40199441) found:
- Global median CT was 20.1 in pulmonary TB patients
- CT correlated strongly with smear grade (r = -0.77,0.001)
- CT correlated with time-to-detection in culture (r = 0.71,0.0001)
- CT values predict culture positivity at Day 15 (p<0.0001)
*DECISION MAKING:*
- *MTB Positive:* CT 22 confirms active tuberculosis
- *Treatment Required:* Immediate anti-TB therapy indicated
- *Infection Control:* Significant infectiousness warrants isolation precautions
- *Monitoring:* Serial CT values can track treatment response
*REFERENCE:*
Mechai F, et al. "Usefulness of the GeneXpert MTB/RIF Ct for predicting tuberculosis infectiousness." Infect Dis Now. 2025 Jun;55(4):105061. PMID: 40199441
The CT 22 value represents a clinically significant bacterial load requiring prompt treatment and infection control measures.
[4:20 pm, 10/04/2026] Aditya: @Rakesh Biswas Sir this is DeepSeek v3.2 now. Let's see how this performs. Started off well I would say.
[4:26 pm, 10/04/2026] Rakesh Biswas Sir: @Rakesh Biswas Sir this is DeepSeek v3.2 now. Let's see how this performs. Started off well I would say.
Opened with a boundary and gets a standing ovation 👏👏
[10:26 pm, 10/04/2026] +91 90513 28746: After all our discussion above, the official report provided for this chest X-ray sings volumes about "interpretation!"
This is a blasphemy
[10:40 pm, 10/04/2026] +1 (650) 336-4873: 2 photos
i put this pic on gemini app and asked the above q. Amazed by how smart AI is!
[7:17 am, 11/04/2026] Rakesh Biswas Sir: This is a blasphemy
In most low resource healthcare ecosystems this is normal!
[7:18 am, 11/04/2026] Rakesh Biswas Sir: i put this pic on gemini app and asked the above q. Amazed by how smart AI is!
I guess it's the same Gemini which also answered that question similarly above
[7:20 am, 11/04/2026] Rakesh Biswas Sir: i put this pic on gemini app and asked the above q. Amazed by how smart AI is!
Check out how we made it respond and compare the similar PCR test for mtb across two patient groups. Shall share again in the 69M group to make it highlight the similarities and differences in the two ways this PCR mtb detection is represented in the two different reports
[4:26 pm, 11/04/2026] Rakesh Biswas Sir: @PaJR Health please share this case report in an imrad format to be updated later on top of the page here: https://pajrpublications.gadelab.com/22f-fever-since-6-months-weight-loss-telangana-pajr/
[4:27 pm, 11/04/2026] PaJR Health: *INTRODUCTION*
*Case Title:* 22F Fever since 6 months, weight loss Telangana PaJR
*Patient:* 22-year-old Female
*Location:* Telangana, India
*Chief Complaints:* Chronic fever (6 months), significant weight loss, persistent cough (2 months), and gastrointestinal distress (vomiting sensation, poor intake).
*METHODS*
*Clinical Evaluation:* Longitudinal history tracking via patient advocate and direct patient interaction.
*Imaging:*
- Chest X-ray (PA View)
- Ultrasound Abdomen & Pelvis
*Laboratory Investigations:*
- Complete Blood Picture (CBP)
- Absolute Leukocyte Counts
- Peripheral Smear Analysis
*Planned Diagnostics:* Sputum AFB and CBNAAT (GeneXpert).
*RESULTS*
*1. Clinical Presentation:*
The patient reported a 6-month history of intermittent fever, which became regular and persistent over the last 20 days. This was accompanied by a 2-month history of cough and significant constitutional symptoms, including weight loss and inability to tolerate full meals due to nausea.
*2. Hematological Findings:*
- *Anemia:* Hb 10.8 g/dL (Low), MCV 78.14 fL (Low), MCH 25.1 pg/dL (Low), indicating microcytic hypochromic anemia.
- *Inflammatory Markers:* Total WBC 13,970 (High) with Neutrophilia (85%) and Lymphopenia (5%).
- *Platelets:* Reactive thrombocytosis (5.71 lakhs/mm³).
- *Smear:* Confirmed neutrophilic leukocytosis and thrombocytosis.
*3. Imaging Findings:*
- *Chest X-ray:* Extensive bilateral patchy and nodular opacification. A prominent thick-walled cavitary lesion is visible in the right upper zone. Massive, dense opacification ("white-out") of the left mid and lower zones, obscuring the left heart border and hemidiaphragm (positive silhouette sign).
- *Ultrasound Abdomen:* Multiple enlarged mesenteric lymph nodes in the Right Iliac Fossa (largest 11 mm).
- *Incidental Finding:* Hypoplastic uterus ($4 \times 1.2 \text{ cm}$) and non-visualized ovaries, suggesting potential endocrine/developmental issues.
*4. Diagnostic Discrepancy:*
An official radiology report (dated 09-04-2026) incorrectly interpreted the chest X-ray as "normal," attributing the left-sided opacification to a "breast shadow." This was clinically refuted by multiple physician reviews of the actual film, which showed clear evidence of advanced pulmonary disease.
*DISCUSSION*
*Clinical Correlation:*
The constellation of chronic fever, weight loss, cavitary lung disease, mesenteric lymphadenopathy, and reactive hematological changes (anemia of chronic disease, neutrophilia, thrombocytosis) is highly pathognomonic for *Disseminated Tuberculosis (Pulmonary and Abdominal)*.
*Management Plan:*
- *Urgent Action:* Initiation of definitive Anti-Tubercular Therapy (ATT) is the highest priority.
- *Verification:* Sputum AFB and CBNAAT are required to confirm the diagnosis and check for drug resistance (Rifampicin).
- *Supportive Care:* Symptomatic relief for cough (currently using Morepen Cough-X BR) and nutritional support.
- *Follow-up:* Endocrine evaluation for the hypoplastic uterus and non-visualized ovaries once the acute infectious process is stabilized.
*Conclusion:*
This case highlights the critical importance of physician-led image review over relying solely on written reports, especially when clinical symptoms (6 months of fever and weight loss) strongly suggest a severe underlying pathology like Koch's disease.
🔗 *Case Link:* https://pajrpublications.gadelab.com/22f-fever-since-6-months-weight-loss-telangana-pajr/
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