Interesting Case

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Interesting Case

• M IV

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• A 24 yr old female
• Staff nurse in Tuberculosis Hospital , Pune
• Came to casualty with c/o
• Fever since 23 days
• Non Pruritic Red Erythematous Rash over upper ,
  lower limbs and abdomen since 22 days

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History of present illness

• Fever not associated with chills rigors
• No h/o chest pain, palpitations, syncope
• No h/o cough , breathlessness
• No h/o abdominal pain
• No h/o burning micturition
• Bowels normal
• No h/o weakness of limbs or any other
  neurological complaint

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• She was referred to a higher centre ( Ruby Grand
  Hospital ) , admitted detected to have raised
  WBC, low Platelet ,IgM Leptospira ve
• Was treated with LINEZOLID, CRYSTALLINE
  PENICILLIN
• Fever did not subside and she also developed
  loose stools ,
  4 5 episodes /day, no
  mucus , blood in stool
• So , came here for further management

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Past History

• No h/o typhoid, malaria, tuberculosis
• Not a known diabetic / hypertensive
• Family History
• No h/o Diabetes , hypertension , tuberculosis
  among family members
• Personel History
• Takes mixed diet
• Decreased appetite
• Sleep normal
• Married, no children yet

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General examination

• Conscious , coherent
• No pallor,icterus,cyanosis,clubbing, pedal edema
• Lymphadenopathy
• B/L cervical lymphadenopathy
• multiple small lymph nodes, mobile, nonmatted,
  nontender,skin over the lymph nodes pinchable

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Vitals

• Pulse 105 / min, regular, low volume , . No
  Vessel wall thickening, No radio femoral delay
• BP 90/60 mm Hg Lt upper limb supine
• Temp 98.6 F
• RR 18/min , Thoracoabdominal, regular
• JVP not elevated
• Thyroid no swelling
• Breast no lump palpable

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• Respiratory System
• trachea mid-line
• b/l normal vesicular breath sounds
• no added sounds
• Gastrointestinal System
• oral cavity normal
• abdomen soft, no tenderness,
  no hepatosplenomegaly, bowel
  sounds

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• Cardiovascular System
• Tachycardia, S1, S2, no murmurs
• Nervous Systems
• HMF normal
• No cranial nerve palsies
• No sensory motor deficit
• No cerebellar signs
• DTR b/l
• Plantars b/l flexor
• No neck stiffness

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Provisional diagnosis

• Pyrexia of Unknown Origin
• Possibilities Leptospirosis / -Myocarditis
• Collagen Vascular Ds- SLE
• Tuberculosis

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Investigations

• WBC 14.9 K / Ul
• DC N- 90 L-3.84 E-2.98
• Hb 9.18 g/dl
• Platelet 157K/Ul
• ESR 70 mm
• Blood Urea 50.8mg/dl
• S.Creatinine 1.63mg/dl
• S.Bilirubin 0.6mg/dl
• Direct Bilirubin 0.1mg/dl
• SGOT 213.4 IU/L
• SGPT 47.4 IU/L
• ALP 110.5 IU/L
• Total protein 8 g/dl
• S.Albumin 2.9 g/dl S.Globulin 5.1 g/dl

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• CK total 170.4U/L
• CK MB 30.3 IU/L
• Trop I 0.001 ng/ml
• Na 132.3 mmol/L
• K 3.9 mmol/L
• Urine R/E m/s 10 -15 pus cells
• 8-10 RBCs
• Granular casts
• bacteria /
  hpf
• protein 2
• blood 2
• glucose negative

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• Echocardiogram
• Normal chamber dimensions
• Good LV function
• EF 60
• Trivial pericardial effusion
• Myocarditis ruled out

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• Started on IV CP 20 LAKH UNITS Q 6hrly
• IV CEFTRIAXONE 2g BD
• Urine C/S No growth
• Rpt Urine R/E Normal
• Blood C/S Aerobic No growth
• Anaerobic No growth
• USG Abdomen mild splenomegaly

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• Peripheral Smear Normocytic normochromic
  anaemia neutrophilia
• QBC for MP Negative
• Smear for MP MF Negative
• FNAC Rt Posterior Cervical Lymph Node
• Morphological features are consistant with
  reactive lymphadenitis and plasmacytosis

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• Dengue IgM Negative (0.017PBU)
• Leptospira IgM Equivocal (9.944PBU)
• Mantoux negative
• Preop serology
• HIV Emergency screen negative ( 0.11 )
• HBsAg Emergency screen negative (0.17)
• Anti HCV Emergency screen negative
• 
  (0.19)

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• Bone Marrow Aspiration Biopsy done
• BM Aspirate diluted marrow
• BM Biopsy Section showed fragmented pieces of
  bony trabeculae intervened by erythroid, maturing
  myeloid cells, megakaryocytes. No abnormal cell
  infiltrate / granuloma seen

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• Bone Marrow Aerobic C/S No Growth
• BM Anaerobic C/S Coagulase negative
• Staphylococci
  
• sensitive Vancomycin, Cotrimoxazole,
• Linezolid
• So, Staphylococcal septicemia was considered and
  IV VANCOMYCIN 1g BD
• started.

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• Fever persisted . 102 F- 103 F daily even after 6
  days of VANCOMYCIN
• Meanwhile ANA reports
• ANA Screen 0.92
• Anti ds DNA 22.11 IU/ml
• ANA profile
• Anti Scl 70 negative
• Anti Jo negative
• Anti SS-A negative
• Anti SS-B negative
• Anti RNP negative
• Anti Sm negative

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• SLE considered unlikely

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• CT Chest Abdomen with Contrast done
• Report
• CT Chest Segmental subsegemental atelectasis
  involving both sides basal segments,Rt middle
  lobe,lingular segment
• no evidence of any obstructive cause for the
  same identified.
• Few slightly enlarged lymph nodes in both
  axillae.
• No significant mediastinal lymphadenopathy

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• CT Abdomen
• Hepatosplenomegaly
• No focal parenchymal lesions
• B/L inguinal lymphadenopathy
• No other significant abnormality detected
  within the abdomen.

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• ? LYMPHOMA
• ? SARCOIDOSIS
• ? TUBERCULOSIS

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• S.LDH 1922 U/L ( 0-240 U/L )
• S.ACE 85 U/L ( 5 -52 U/L )
• Coombs direct negative
• Coombs indirect negative
• Excisional biopsy of Rt axillary lymphnode
  report awaited

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• Lymphnode biopsy report awaited she was started
  on 2 nd line ATT (d/t deranged LFT)
• Tab.AZITHROMYCIN 500mg OD
• Tab.OFLOX 400mg BD
• Tab.ETHAMBUTOL 800mg OD

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• Lymph Node Biopsy
  CLASSIC HODGKINS LYMPHOMA
• ( Lymphocyte Rich Type )

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Hodgkins Lymphoma

• Painless palpable lymphadenopathy
• Lymph nodes in neck, supraclavicular area and
  axilla.
• More than half have medistinal lymphadenopathy at
  diagnosis and this is sometimes the initial
  manifestation
• Sub-diaphragmatic lymphadenopathy unusual
  more common in older males
• 1/3rd of pts present with fever, night sweats and
  wt loss.
• Histological landmark REED-STERNBERG CELL

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• It can present as PUO,
• Fever might persist for days to weeks, followed
  by afebrile period then recurrence of fever
  Pel-Ebstein Fever
• Rarely severe, unexplained itching, erythema
  nodosum, icthyosiform atrophy, paraneoplastic
  cerebellar degeneration, nephrotic syndrome,
  immune hemolytic anemia, thrombocythemia,
  hypercalcemia pain in lymph nodes on alcohol
  ingestion.

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• Bimodal age distribution
• one peak in 20-35 yrs
• 2nd peak over age 50yrs
• Types
• Nodular lymphocyte predominant
• Classical HL Nodular sclerosing 70
• Mixed cellularity 20
• Lymphocyte-rich 5
• Lymphocyte-depleted
  rare
• D/D inflammatory processes, inf.mononucleosis,
  NHL, Phenytoin induced adenopathy non
  lymphomatous malignancies

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Investigations

• CBC normal / normocytic normochromic anemia
  lymphopenia / eosinophilia neutrophilia
• ESR raised
• RFT
• LFT altered hepatic infiltration
• obstructive pattern nodes at porta
  
• 
  hepatis
• S.LDH raised levels
• CXR may be mediastinal mass
• CT Scan Chest Abd
• Lymph Node Biopsy

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Ann-Arbor Staging

• Stage
• I
• II
• III
• IV

• Definition
• Inv of single lymph node region /
• lymphoid structure
• Inv of 2 / more lymph node regions on
• same side of diaphragm
• Inv of lymph node regions / lymphoid structures
  on both sides of diaphragm
• Disseminated ds inv bone marrow / liver

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• A - No symptoms
• B Unexplained wt loss of gt 10 of bd.wt
• during 6months before staging invg
• - Unexplained, persistant or recurrent
• fever with tempgt38C prev month
• - Recurrent drenching night sweats
• during prev month

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Treatment

• Radiotherapy
• Stage I ds
• Stage II A ds with three / fewer areas inv
• After Chemotherapy to sites where there was
  originally bulk ds
• To lesions causing serious pressure problems
• Chemotherapy
• All pts with B symptoms
• Stage II with gt 3 areas inv
• Stage III and IV

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• ABVD regimen Adriamycin (Doxorubicin)
• Bleomycin
• Vinblastin
• Dacarbazine
• MOPP regimen Meclorethamine
• 
  Oncovin(Vincristine)
• Procarbazine
• Prednisone

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Side effects

• Second malignancy
• Cardiac injury
• Risk of development of acute leukemia greater
  with MOPP rather than with ABVD
• Infertility
• Radiation hypothyroidism
• malignancies
• Lhermittes syndrome

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