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fever & LN.pptx

  1. Fever and lymphadenopathy Presenter: Dr Junaid Yousuf PG resident General medicine Consultant Incharge: Dr Afaq (Asst. Prof. clinical hematology) SR Incharge : Dr Satya Prasad Namala
  2. Patient Profile • 60y/F • Married having 5 kids • Resident of Poonch, J&K • Housewife
  3. Chief complains • Fever -4weeks • Swelling over neck-3 weeks.
  4. History of present illness: FEVER • Duration-4 weeks • Documented with max spike of 103F. • Intermittent • Predominantly evening rise • With short term relief by antipyretics • Also received IV antibiotics (Ceftriaxone 1 gm IV BD for 1 week), with no response.
  5. History of present illness • Associated with chills, increased sweating. • Abdominal pain, located left upper abdomen. • Dragging in nature, mild intensity, with short term relief by analgesics. • Significant weight loss of 10 kgs in 2 months. • Loss of appetite. • Easy fatiguability and generalized weakness.
  6. No history of • Cough, dysnoea. • Chest pain. • Loose stools. • Jaundice. • Dysuria, frequency, hematuria, urethral discharge.
  7. No history of • Headache, photophobia, abnormal movements. • Rash • Contact with animals • Recent travel to outside • High risk behavior • Morning stiffness • Joint pains • Dry eyes • Bony pains
  8. History of present illness contd.. NECK SWELLING • Duration 3 weeks. • Located in the left side of neck. • Noticed by patient herself. • Small swelling ,with no associated pain or any discharge. • Progressive increase in swelling over this time.
  9. Past illness • Patient is a known case of T2DM for 3 years on oral diabetic drugs, uncomplicated as per records. • No history of similar illness in the past. • No history of HTN, thyroid disorders, old treated malignancy, old treated tuberculosis.
  10. Personal history • Post menopausal. • Having 5 kids. • Mixed diet. • Normal bowel/bladder. • Decreased sleep and appetite.
  11. Family history • History of hypertension and T2DM in mother. • No history of malignancy in family. • No h/o ATT intake in family.
  12. Drug history • Metformin 500+Glimepride2mg from 3 years. • Received I.V antibiotics for 1 week (Ceftriaxone 1 gm BD) prior to our admission.
  13. SUMMARY • 60/F underlying T2DM with a 4 week history of fever and neck swelling with associated h/o constitutional symptoms in the form of generalized weakness, mild left upper abdominal discomfort and weight loss.
  14. Differentials Infections Viral (EBV/CMV/HIV)/ Viral Hepatitis EBV CMV HIV No URTI, Duration, No Myalgias Fever and Lymphadenopathy Fever and Lymphadenopathy No High risk behavior Fever and Lymphadenopathy, Weight Loss No URTI Viral Hepatitis Fever and abdominal pain Lymphadenopathy
  15. Differentials Infections Bacterial • TB • Brucella • CAT scratch • Atypical MTB TB Brucella CAT Duration, No contacts, No RT symptoms Fever, Weight loss and Lymphadenopathy Fever and Lymphadenopathy No rash/scratch Fever and Lymphadenopathy, No animal contact Atypical Mycobacteria Fever and Lymphadenopathy, No RT Symptoms/ No IS
  16. Differentials Infections Parasitic • Toxoplasma Fever and Lymphadenopathy Duration of fever, No Immuno suppressed state
  17. Differentials Malignancies • Lymphomas • Leukemias • Solid Organ Lymphoma Leukemia Age, Fever, Lymphadenopathy & B Symptoms Age, Fever, Lymphadenopathy No bony pains, bleeding Solid organ Malignancies Lymphadenopathy, Weight loss Fever
  18. Differentials CTD SLE Sjogrens Scleroderma MCTD SLE MCTD Sjogrens No rash, arthralgias or ulcers Age, Fever, Weight loss and Lymphadenopathy Age, Fever, Weight loss and Lymphadenopathy No SICCA Age, Fever, Weight loss and Lymphadenopathy No rash, arthralgias or ulcers Scleroderma Age, Fever, Weight loss and Lymphadenopathy No Dermatology
  19. Differentials Others Lymphoma mimics • Kikuchi • Castlemans • Rosai Dorfmans • Sarcoidosis Kikuchi Castleman’s RD Age, Fever, Weight loss and Lymphadenopathy Age, Fever, Weight loss and Lymphadenopathy Duration, large nodes, relapses and remissions Age, Fever, Weight loss and Lymphadenopathy Duration, large nodes, relapses and remissions Sarcoidosis Age, Fever, Weight loss and Lymphadenopathy No RT symptoms
  20. Examination • Patient is conscious cooperative oriented to time, place and person. • Pulse: 92 regular synchronous with the other side, and other pulses normal. • Bp :110/70 mmhg • Sp02 : 94% RA • RR: 18/min
  21. General Examination • Pallor: Present • Icterus: Present • Cyanosis: absent • Pedal edema present • JVP not raised
  22. Neck • Cervical lymphadenopathy present • 2 x 1.5 cm node present in left posterior triangle level 5 • Firm in consistency. • Mobile • Non tender • Overlying skin normal • Multiple other nodes less than one cm in b/l neck level 2 & 3. • Thyroid: No goitre.
  23. Oral Cavity • Tongue moist. • Normal faucial pillars. • Post pharyngeal wall normal. • No tonsillar hypertrophy. Normal breast examination.
  24. Axilla/Inguinal • Axilla : Multiple nodes largest around 2cm freely movable present in left axilla non tender • Inguinal region- no inguinal LAP • Nails no clubbing, discoloration of nails.
  25. Chest examination • Inspection: Normal shape, no deformity, no scar or dilated veins, symmetrical rise of chest • Palpation: No tenderness, symmetrical chest movements. Chest expansion 6 cm. • Percussion: normal resonant note heard all over lung fields except area of cardiac dullness. • Auscultation: Normal vesicular breath sounds. No crepts/wheeze.
  26. CVS • Inspection: No deformity, apex not visualized. • Palpation: Cardiac apex felt in 5th i/c space. • Percussion: Area of cardiac dullness in 4th to 6th i/c space. • Auscultation.S1S2 heard in all areas of auscultation ,no added sounds or murmurs.
  27. Central nervous system • HMF: normal • Sensory system: normal • Motor system: Normal • Reflexes: Present • Cerebellar Signs: absent
  28. Abdominal examination • Normal contour, umbilicus inverted no visible colour change or dilated veins/scars. • Mild hepatomegaly, liver palpated 3 cm below costal margin, with normal consistency of inferior border. Liver span 17 cm. • Moderate splenomegaly, spleen palpated 5 cm below coastal margin midway between coastal margin and umbilicus. • No other palpable organ/mass. • No fluid thrill, no shifting dullness.
  29. Summary • 60 year female with B symptoms and lymphadenopathy and hepatosplenomegaly. • Possibilities : ??
  30. Differential diagnosis on history and examination • Malignancies Likely, hematological (Lymphoma, Leukemias). • Infections : Tuberculosis. • Auto Immune. • Viral hepatitis. • Others atypical lymphoproliferative disorders. • Solid organ Malignancies.
  31. Investigations: • Hb: 7.1, TC: 5.6, PLT: 24, Normal: N/L/M: 65/20/13. MCV: 92, ESR: 72. • PBF: Normocytic anemia, severe thrombocytopenia, no abnormal cells. • Urea, Creat: 40/1.2 • Calcium: 8.0 • Phosphorous: 3.84. • LDH: 960. CPK: 46, UA: 5.96. • Retic: 2.5. • BIL: 8.4 (I/D): 4.4/4.0. • ALT: 26, ALP: 455, TP: 5.8, ALB: 2.45. • PT: 15, INR: 1.1, APTT: 29.
  32. Investigations: • pH:7.40, Hco3:19, Na: 148, K: 3.66, pCo2:32. • RUE: 2-4 pus cells, no protein, no rbcs. • ECG: Sinus rhythm. • Xray Chest: Normal, no mediastinal widening, no effusions.
  33. Investigations: • Bone marrow aspiration. Hypercellular marrow with normal cell lines, no infiltration in aspirate smears, no blasts, no atypical cells. • Bone marrow biopsy: awaited, have to rule out infiltration in view of unexplained cytopenias.
  34. Investigations: • Blood/urine culture: Sterile • Sputum g/s; culture: negative • Sputum for AFB : no AFB seen • Mantoux: Negative. • ICT/DCT: Negative.
  35. Radiological investigations : USG • Spleen is 16 cm, enlarged in size. Hypoechoic lesions in b/l adrenal glands. • Multiple enlarged lymph nodes seen in peripancreatic, periportal, paraaortic locations with maximum of 26 mm. • Liver is enlarged in size with few hypoechoic lesions seen in both lobes largest one 38*33,IHBRD and CBD not dilated • Segmental area of circumferential thickening in small bowel in left iliac fossa.
  36. CECT abdomen & Pelvis • Bilobar hypovascular hepatic leisions. • Areas of segmental circumferential mural thickening of small bowel(jejenum/ileum). • Multiple enlarged occasionally conglomerating, periportal peripancreatic, paracaval and mesenteric lymph nodes. • Bilateral adrenal masses with small hypodense non enhancing area.
  37. HPE Cervical LN excision bx • Sheets of round to oval cells with hyperchromatic nuclei and mild amount of cytoplasm suggestive of poorly differentiated carcinoma/non Hodgkin lymphoma IHC Positive makers-LCA/CD20/ki67/CD79a/PAX5 Negative markers: SOX11/BCL6/CD10/CD23/CD30 High grade b cell lymphoma DIFFUSE LARGE B CELL LYMPHOMA Diffuse large B cell lymphoma. The majority of cases contain a mixture of large cells that resemble centroblasts with peripheral nucleoli and a minority of large cells that resemble immunoblasts with central nucleoli.
  38. Final diagnosis Diffuse large B cell lymphoma Stage III
  39. Management • Patient was started on R-CVP protocol after confirming of diagnosis and received 1st cycle uneventfully. • After starting the chemotherapy her, bilirubin has plumped down to normal. • Lymphadenopathy reduced in volume. • Her GC has improved, now asymptomatic. • She is being discharged today.