WELCOME
A 22-year-old female presented with upper lip swelling and fever
Dr. Khadiza Akter
MD Resident (Phase-A)
Green Unit
Department of Haematology
BSMMU
Particulars of the patient
Presenting Complaints
History of present illness
According to the statement of the patient, she was reasonably well 2 ½ months back. Then she noticed a swelling over the right side of the upper lip. Swelling was painless, brownish color, gradually increasing in size with irregular surface & distorting the shape of upper lip. swelling was associated with discharge which was whitish in color & not admixed with blood.
History of present illness (cont’d..)
She also complaints of fever for last 2 months which was low grade, intermittent, highest temperature was recorded 100°F. Fever was not associated with chill & rigor, night sweat & was subsided after taking antipyretic.
On query, she gave history of weakness and gradual weight loss (approximately 8 kg in last 6 month)
There was no history of cough, sputum, hemoptysis & contact with TB patient. Her bowel & bladder habit is normal.
History of Past illness
She had history of same type of swelling in the right thigh about 6 months back which was resolved 2 months later, then another swelling developed over upper part of the left arm 4 months back which was also resolved spontaneously.
No previous history of radiation therapy or other significant chronic illness.
Treatment History
Family History
Parents are alive. She has 3 siblings. All of them are doing well.
Personal History:
No history of betel nut chewing, smoking or taking alcohol.
Obstetric history
Menstrual period 3-5 days
Immunization history:
Socioeconomic History
Physical examination
General Examination
General Examination(cont’d…)
General Examination(cont’d…)
Systemic Examination
Gastrointestinal system
side of the upper lip. Approx.(5cm x
3cm) irregular shape, rough surface,
brownish color, hard in consistency,
not fixed with underlying structure
whitish discharge, not admixed with
blood. Local temperature not raised.
Gastrointestinal system(cont’d…)
Number: 32
Staining: Absent
Inflammation
Ulceration
Bleeding Absent
Hypertrophy
Swelling
Gastrointestinal system(cont’d…)
Abdomen
Inspection:
Abdomen(cont’d)…
Palpation:
Liver- not palpable
Spleen- not enlarged
Kidneys- not ballotable
Abdomen(cont’d)…
Percussion:
Upper border of the liver dullness: right 5th intercostal space along the mid-clavicular line
No evidence of ascites (no fluid thrill, no shifting dullness).
Auscultation:
Other system
Cardio-Vascular system
Respiratory system Reveals normal findings
Nervous system
Musculoskeletal system
���What will be the diagnosis ?������?????
Differential diagnosis
Investigations (Blood)
CBC with ESR | 8/02/2022 | 23/02/2022 | 10/03/2022 |
Hb | 12.3 gm/dl | 11.1gm/dl | 10.8gm/dl |
ESR | 35 mm in 1st hr | 40 mm in 1st hr | 25 mm in 1st hr |
RBC | 4,22,000 | 3,77,000 | 3,69,000 |
Platelet | 1,50,000 | 2,10,000 | 2,25,000 |
TC | 4,500 | 4,000 | 6,500 |
MCV | 89.6fl | 91.8fl | 91.3fl |
MCH | 29.1pg | 29.4pg | 29.3pg |
MCHC | 32.5g/l | 32.1g/l | 32g/l |
RDW | 12.8% | 13.5% | 14.3% |
Investigations(cont’d…)
CRP | 36.6 mg/L | 8/02/2022 |
S. Ferritin | 298.1 ng/mL(N : 10-120) | 10/02/2022 |
S. Folate | 18.1 ng/mL | 10/02/2022 |
S. Vit-B12 | 1210 pg/mL (N:107-653) | 10/02/2022 |
TIBC | 225 mcg/dl | 10/02/2022 |
Iron | 22 mcg/dl | 10/02/2022 |
S. Albumin | 42 g/L | 13/02/2022 |
S. bilirubin | 0.7 mg/dl | 13/02/2022 |
Investigations(cont’d…)
HIV | Negative | 13/02/2022 |
ALP | 17 U/L | 13/02/2022 |
SGPT | 64 U/L | 13/02/2022 |
AST/SGOT | 31 U/L | 13/02/2022 |
HBsAg, Anti HCV | Negative | 13/02/2022 |
S.Uric Acid | 2.7 mg/dl | 23/02/2022 |
LDH | 394 U/L | 23/02/2022 |
RT-PCR for Covid-19 | Negative | 01/03/2022 |
Investigations(cont’d…)
S. Creatinine | 0.58 mg/dl | 11/03/2022 |
S.Calcium | 8.7 mg/dl | 11/03/2022 |
S. Inorganic PO4 | 4.4 mg/dl | 11/03/2022 |
RBS | 5.7mmol/L | 11/03/2022 |
S. Electrolytes: Na | 141 mmol/l | 11/03/2022 |
K | 3.7 mmol/L | 11/03/2022 |
Cl- | 107 mmol/L | 11/03/2022 |
T-CO2 | 24.8mmol/L | 11/03/2022 |
ECG
Echocardiography
USG of Upper lip
USG of Upper lip: (09/02/2022)
Comment- Markedly thickened edematous
sub-cutaneous tissue and fat plane with a
ill-defines irregular ill- marginated
heterogeneous hypo to anechoic area
without any low level internal echoes
in the right lateral aspect of upper
lip may be due to – marked cellulitis
with early stage of abscess formation
Pus for C/S: (11/02/2022)
Organism: No swelling
Incubation period: 48 hrs./O2
FNAC from Upper lip: (12/02/2022)
Finding - No malignant cell identified.
- Abundant inflammation favor abscess formation
Histopathology
Histopathology
Histopathology report:(20/02/2022)
Specimen: Tissue from Upper lip
Microscopic description:
Sections of soft tissue show a neoplasm composed of oval to round shape arranged diffusely. These cells are medium in size, having moderate cytoplasm with contorted nuclei. The surface show ulcer. There is infiltration of acute and chronic cells
Diagnosis: Non- Hodgkin Lymphoma
Bone Marrow morphology
Bone Marrow morphology
Examination report: (20/02/2022)
Comments:
Features are suggestive of Myeloid Hyperplasia
Bone marrow Histopathology
Bone marrow Histopathology
Bone marrow Histopathology (Trephine biopsy) Report on 20/02/2022
Microscopic appearance:
Section shows core fo spongy bone. The marrow is mildly hypercellular. Granulopoisis and erythropoisis are active. Megakaryocytes are adequate.
Diagnosis:
Reactive marrow
Immunohistochemistry Report
Immunohistochemistry Report
Soft tissue from upper lip (biopsy) on 21/02/2022
Immunohistochemistry(IH-600/22):
Comment: Anaplastic large cell lymphoma
USG of Whole abdomen (5/03/2022)
Normal Findings
CXR P/A View: (5/03/2022)
Normal Findings
Confirmatory Diagnosis�
Anaplastic large cell lymphoma
Thank You