A 17- YEAR- OLD FEMALE PRESENTED WITH �NECK SWELLING ,FEVER AND SKIN RASH

Dr Mahmudul Hasan

MD resident (phase A)

Blue unit

Department of hematology

BSMMU

Particulars Of The Patient

• Name : Morium Akter
• Age : 17 years
• Sex : Female
• Religion : Islam
• Occupation : Student
• Marital status : Unmarried
• Address : Kurigram
• Date of admission :10/4/2022
• Date of examination : 14/4/2022

Chief Complaints

1. Swelling on left side of neck for three months.
2. Fever for one month.
3. Weakness for one month.
4. Skin rash for ten days.

History Of Present Illness

According to the statement of the patient, she was reasonably well

three months back. Then she noticed a nodular swelling on the left

side of her neck ,which progressively increased in size , painless, not

associated with difficulty in swallowing or change in voice.

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Cont..

She also complains of intermittent low grade fever for one month, highest recorded temperature was 101 °F which relieved by with or without taking paracetamol . Fever is not associated with chills and rigor , there is no diurnal variation .

Cont..

She gives history of weakness for same duration which increases progressively in severity and now hampering her daily activities. It is not associated with breathlessness , palpitation, leg swelling.

Cont..

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The patient also complains of multiple rashes of varying size all over

her body for 10 days which are painless, non itchy ,nonpalpable ,

some are bright red and some are dark pigmented .

There is no history of other bleeding manifestations like epistaxis or gum bleeding.

Cont..

She also gives history of documented weight loss of 5 kgs over last 6 months.

She gives no history of pruritus ,cough , night sweat , oral ulcer, joint pain, previous history of tuberculosis or contact with tuberculous patient. Her bowel bladder habit is normal.

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History of past illness

• No significant history of past illness

family history

• Her parents and siblings are doing well

treatment history

• there is no history of hospitalization or taking any drugs before this illness

Transfusion history

She received three units of PRBC over last one month.

Menstrual History

regularly menstruating woman with normal flow

General examination

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Appearance : ill looking

Body build : Average� cooperation :cooperative� Decubitus : On choice� Anaemia : Moderate� Jaundice : Absent� Cyanosis : Absent� Clubbing : Absent� koilonychia : Absent� Leukonychia : Absent��

Cont..

• Lymph node : There is lymphadenopathy involving left submandibular and both anterior cervical lymph nodes, variable in size, largest one is on the left submandibular region measuring about 4×6 cm , matted, firm, nontender, fixed with underlying structure and free from superficial skin. Superficial skin condition is normal and there is no discharging sinus.

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Cont..

Generalized skin condition : there are multiple pupuric and petechial spots all over the skin, some are discrete and some are confluent, non palpable, non tender, some are bright red and some are dark pigmented, do not blanch on pressure.

• Oral cavity : normal
• Oedema : Absent
• Dehydration : Absent
• Thyroid gland : Not enlarged
• Bony tenderness : Absent

• Pulse : 80 b/min�• BP : 120/80 mm hg�• Temperature : 98 ᵒF�• Respiratory Rate : 20 b/min

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Systemic examination

Abdomen�

Inspection :

Abdomen is scaphoid in shape

Umbilicus is central and inverted

No visible peristalsis

No engorged vein

Superficial palpation

• Tenderness : absent
• Local temperature : normal
• mass : absent
• rigidity : absent

Deep palpation

• There is no palpable mass
• Spleen : spleen is enlarged , about 6 cm from left costal margin along its long axis towards the right iliac fossa ,non tender, firm in consistency ,moves with respiration, finger insinuation is not possible.
• Kidney :not ballotable

Percussion

Shifting dullness: absent

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Auscultation

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Bowel sound : present

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Other system examination

Respiratory system: normal

Cardiovascular system : normal

Musculoskeletal system : normal

Nervous system : normal

Salient feature

�Morium Akter , 17 years old female student , normotensive,  non diabetic hailing from Kurigram presented with the complaints of painless, gradually increased swelling on the left side of the neck for three months not associated with difficulty in swallowing or change in voice.

Cont..

She also complains of intermittent low grade fever for one month, highest recorded temperature is 101ᵒ F, relieves by taking paracetamol and not associated with chills and rigors or diurnal variation.

Cont..

She also complains of progressive generalized weakness for 1 month which is now hampering her daily activities and significant weight loss which is approximately 5 kg over last six months.

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Cont..

She has no history of pruritus, night sweat ,cough, hemoptysis , oral ulcer, arthralgia and alopecia. She didn’t have history of previous TB or contacted with TB patient.

She received three unit of PRBC in last one month .she is a normally menstruating woman. Her bowel bladder habits were also normal .

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Cont..

On general examination she is moderately anaemic , there is non tender cervical lymphadenopathy involving both side , largest one is 4×6 cm in left submandibular region, firm in consistency, ,matted , fixed to the underlying structure.

Cont..

• She has multiple petechial and purpuric rash all over her body. There was no jaundice, clubbing, koilonychia, leukonychia, bony tenderness, thyromegaly. Her pulse -80 b/min, BP- 120/80 mm hg ,temp - 98ᵒF

Cont..

• On systemic examination of abdomen there is splenomegaly of about 6 cm from the left costal margin along its long axis towards the right iliac fossa. no other organomegaly is found.
• Other system examinations are also normal.

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Differential Diagnosis

• Acute leukemia
• Lymphoma
• Disseminated TB

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Investigations

cbc

Peripheral Blood film

• RBC : Normochromic, normocytic, polychromatic cells , elongated cells.
• WBC: Reduced , mature with above count and distribution.
• Platelet : reduced
• Comment : Pancytopenia

Bone marrow examination ( Triphine Biopsy)

• Specimen : Bone marrow (trephine biopsy)
• Gross Examination: specimen consists of a grey white linear bony piece of tissue measuring 2.5 cm . Submitted as such after short decalcification.
• Microscopic appearance : sections made from the submitted specimen show spongy core. It reveals increased cellularity , showing diffuse infiltration of atypical lymphoid cells . megakaryocytes are rarely seen.
• Dx: lymphoproliferative disorder suggestive of acute leukaemia.

Histopathology report

�Microscopic appearance : section shows cores of lymphoid tissue, these have been infiltrated by atypical lymphoreticular cells. most of the cells contain non- cleaved nuclei with open chromatin pattern. cells are mostly monotonous looking.

�Diagnosis : features are suggestive of non- Hodgkin s lymphoma.

Immunohistochemistry report

�Tumour cells show following immunophenotyping

LCA     : positive�CD3     : negative�CD20   : negative�CD79 alpha  : positive�TdT      : positive�CD10   : positive�CD99    : few cells are positive�c- MYC  : negative�ki67   : about  70% cells are positive.�comment :B- acute lymphoblastic leukaemia or lymphoma

Acute leukaemia

Lymphoma

Disseminated TB