Granuloma

Uncertainty is a key word in science and medicine. Classical description of a disease as we learn from the textbooks, and as we admire it in straightforward presentation, is never happening in real life.

"How true," I whispered as I taught my students yesterday on a chest radiograph from a lady with cough and fluid in her lung. As soon as I showed them the picture, most students pointed to the fluid without hesitation.

"So is there anything abnormal you can spot out?" I smiled. They just stared at the film without blinking, their hearts running fast. No one answered. "Look at this cluster of innocent-looking players at the top," I finally spoke aloud, my fingers pointing at the area what we call granulomas – which are nothing but a large aggregate of host cells and tuberculosis bacteria.

"Take one more look at the chest film of your patients," I explained. "And you'll see these footprints left behind after an attack by the tuberculosis." Although this is for student learning, it's not just for them to learn. I'm learning too. When I went back to my office and read up the topic from the recent issue of the medical journal Lancet, I began to know more about the microbial mystery of granuloma. This is an eerie thought when I found out new theory about granuloma. In the old days, granuloma seems like a cocoon keeping the tuberculosis in quarantine. Now, we're taught that the granuloma also provides the primary growth niche for this organism. Another way of looking at this granuloma is to view its wall as shielding itself from immune-based killing mechanisms and making it very difficult for antituberculosis drugs to penetrate. Granulomas, alas, are no longer considered an innocent guy.

Classifying anyone as distinct binary categories - either good guy or bad guy - is overly simplistic, I know.