A 29-years-old-female presented with generalized weakness & weight loss.
Dr Taherul Islam
FCPS P-II Trainee
Department of Medicine
BSMMU
Particular's of the patient
Presenting Complaints
History of present illness
According to the statement of the patient she was reasonably well 1 year back.Then she developed fever, which was low grade,intermitent in nature, lasted for 5-6 days, twice/thrice episodes in a month, releaved by taking antipyretics, not associated with chills and rigor,cough,abdominal pain,burning micturation or any other systemic menifestations.
She also complaints of repeated gum bleeding for same duration which was spontaneously resolved & there is no other bleeding history.
She also complaints of generalized weakness inspite of doing daily activities but feels tired all the day. There is no h/o proximal muscle weakness, photosensitivity,malar rash or oral ulcer but hair loss for 5 months. Patient also gave h/o documented weight loss of 5-6 kg in last 5 months without obvious cause of chronic diarrhoea. She has no history of sweating at night,pruritus or bony pain.She is normotensive & non-diabetic.Her bowel & bladder habit are normal..With these complaints she went to a physician & was evaluated. A single lymph node was palpable that time on left anterior cervical region & it was excised.
History of past illness
She gave h/o 1 unit blood transfusion in last 1 year.
Treatment History
The patient was given symptomatic treatment for her illness.History of taking tab cortan (30 mg) for 3 months in last year.
Family History
Her parents & siblings all are doing well.
Immunization History
She was immunized according to EPI schedule
Socioeconomic History
The patient is from middle class family
Menstrual History
Cycle: Regular, Flow: Normal
Physical Examination
General Examination
Systemic Examination
Abdomen
Inspection
Abdomen is scaphoid in shape,umbilicus is central & inverted in shape, no visible peristalsis , no engorged vein
Superficial palpation:
Local Temperature: normal, no tenderness,no rigidity, no mass,
Deep palpation:
There is no palpable mass,
Liver: not palpable
Spleen: spleen is palpable 4 cm from left costal margin along the anterior axillary line.
Kidney is not ballotable
Percussion:
percussion note is dull over spleen but resonant in rest of the abdomen , there is no shifting dullness
Auscultation:
Bowel sound: present , No bruit
Salient features
Mrs. Nargis Akter,29 yrs old normotensive,non-diabetic female hailing from Demra,Amulia, presented with the complaints of generalized weakness and weight loss for 5 months.She also complaints of generalized abdominal discomfort along with abdominal pain for 1 year which was diffuse, dull in nature,not associated with food, relieved by taking medication.
The patient has a 1 year history of irregular,on & off fever which lasted for 5-6 days, twice/thrice episodes in a month.Fever was lowgrade,intermitent in nature, releaved with antipyretics, not associated with chills and rigor,cough,abdominal pain,burning micturation or any other systemic menifestations.She also complaints of repeated gum bleeding for same duration which was spontaneously resolved.She gave no other bleeding history.
She has no history of sweating at night,pruritus,photosensitivity or bony pain.She gave H/O 1 unit blood transfusion in last 1 year.There was no previous H/O blood transfusion.Her menstrual cycle is regular & flow is normal.Bowel,bladder habit is also normal.On drug history history she told about taking tab cortan for 3 months in last year.On general examination,we found that the patient was mildly anaemic,no jaundice,cyanosis,clubbing,koilonychia or leuconychia.
Differential Diagnosis
Investigations
CBC
CBC with ESR | 11/01/22 | 02/04/22 | 05/12/22 |
Haemoglobin | 7.3 gm/dl | 10.7 gm/dl | 9.2 gm/dl |
ESR | 35 mm in 1st hr | 42 mm in 1st hr | 50 mm in 1st hr |
Total RBC Count | 2.8*10^12/L | 3.57*10^12/L | 3.46*10^12/L |
Total WBC Count | 3.5*10^9/L | 3.0*10^9/L | 2.5*10^9/L |
CBC with ESR | 11/01/22 | 02/04/22 | 05/12/22 |
Total Platelet Count | 80*10^9/L | 60*10^9/L | 110*10^9/L |
Neutrophil | 62% | 56% | 65% |
Lymphocyte | 31% | 33% | 23% |
Monocyte | 3% | 8% | 10% |
CBC with ESR | 30/03/21 | 02/10/21 | 22/03/22 |
Eosinophil | 4% | 3% | 2% |
Basophil | 0% | 0% | 0% |
Test on 05/12/22 | Result |
serum Bilirubin | 0.9 mg/dL |
RBS | 5 mmol/L |
serum sodium | 131 mmol/L |
serum potassium | 4 mmol/L |
LDH | 162 U/L |
uric acid | 5 mg/dL |
SGPT | 45 U/L |
serum creatinine | 0.86 mg/dL |
ss-A/Ro60KD- positive
SS-B/La -positive
Histopathology of lymph node biopsy (10/12/21)
Gross Description :
Specimen consist of an enlarged lymph node.It measures 1.3*1*0.8 cm.Embedded whole in two pieces.
Microscopic Findings:
Section shows lymph node.It reveals features of chronic non-specific lymphadenitis.No granuloma or malignancy is seen.
Impression:Lymph node: chronic non-specific lymphadenitis.
Immunohistochemistry (14/12/22)
Impression: classical Hodgkin Lymphoma
Immunoreactive in RS cell: CD30,OCT-2,CD15
Peripheral blood film (10/12/22)
Bone Marrow Report ( 15/12/22)
Chest x ray P/A view (10/12/21)
CT scan of whole abdomen (15/12/22)
Next plan:
: Core biopsy from abdominal lymph node.
: Splenic puncture
Connective tissue disease(possibly SLE)
| Points in favour | Points against |
Clinical | Young female | No arthralgia |
| Weakness | Lymphadenopathy�� |
| Alopecia | No skin rash/photosensitivity |
Laboratory findings | Pulmonary infection | Negative Anti Ds Antibody |
| Pancytopenia� | No renal/cardiac involvement |
| ANA positive | |
| | |
Disseminated TB
| Points in favour | Points against |
Clinical: | Fever | No night sweating |
| Weight loss | No cough |
| Palpable single cervical lymph node | No bone pain |
| Abdominal involvement | |
Laboratory findings | Pancytopenia | Mantaux test negative |
| Pulmonary infection | Chest x ray normal |
| | |
Lymphoma
| Points in favour | Points against |
Clinical | Palpable single cervical lymph�node | No evidence of night sweat |
| Fever | No pruritus |
| Splenomegaly | Alopecia |
| weakness | |
| weight loss | |
Labratory findings | Pancytopenia | ANA positive |
| EBV positive | Normal serum LDH level |
Thank you