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A 60-year-old male presented with fever, weight loss, vomiting & abdominal lump�

Dr. Morsheda Akter Jhorna

MD Resident (Phase-A)

Yellow Unit

Department of Haematology

BSMMU

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Particulars of the patient

  • Name:Akkas Ajij
  • Age: 60 years
  • Sex: Male
  • Religion: Muslim
  • Occupation: Businessman
  • Address: Kumilla
  • Date of Admission: 22th April, 2022
  • Date of Examination: 27th April,2022

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Presenting Complaints

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  • Fever for 4 months.
  • Weight loss &
  • Upper abdominal lump for same duration

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History of present illness

Recurrent bouts of fever followed by apyrexial period, persisted for 3-4 days, twice in a month for 4 months. Fever was-

-low grade,

-intermittent in nature,

-highest recorded temperature was 100 0 F,

-no evening rise of temperature,

-associated with drenching night sweat,

-relieved by taking antipyretics.

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cont’d..

No H/O cough ,abdominal pain, diarrhoea, burning micturition, bone or joint pain.

On query, he also complained of nausea & occasional vomiting which occurs-

-after taking food,

-contains food materials,

-no blood or bile,

-not induced, non projectile.

He gave h/0 weight loss about 6 kg in last 4 months which was unintentional.

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cont’d..

  • He also complaints of a feeling a painless lump in upper abdomen for 4 months which is slowly increasing in size.

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  • He had no history of bleeding from any site.

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  • His bowel & bladder habbit and sleep pattern is normal.

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History of Past illness

  • He was diagnosed a case of disseminated TB on 2018 (LN, gastric tissue biopsy) & got category-1 therapy.
  • Minor improvement> re-evaluation
  • Diagnosis as DLBCL on the basis of gastric tissue biopsy, IHC & recieved 6 cycles chemotherapy with CHOP. After that he was symptom free for about 2 years.

Drug History

  • Category-I anti TB
  • CHOP chemotherapy

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Family History

No significant family history

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Personal History

No history of betel nut chewing, smoking or taking alcohol.

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Immunization history

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  • He is immunized according to EPI schedule. He gave no adult immunization history.
  • He took 2dose of Covid vaccine.

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Socioeconomic History

  • Low socio-economic status

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Physical examination

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General Examination

  • Appearance- Ill looking, emaciated.
  • Body build- Below average
  • Decubitus- On choice
  • Anemia- Mildly Anemic
  • Jaundice- Absent
  • Cyanosis- Absent
  • Clubbing- Absent
  • Edema- Absent
  • Bony tenderness: Absent

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cont’d…

  • Koilonychia- Absent
  • Leuconychia- Absent
  • Dehydration- Absent
  • Skin condition: Normal
  • Lymph nodes-No palpable lymphnode
  • Thyroid gland- Not enlarged
  • Neck Veins- Not engorged
  • Pulse- 76 b/p/m
  • BP- 130/80 mm hg
  • Temperature- 98℉
  • Respiratory rate- 18/min

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Systemic Examination

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Alimentary system

Oral cavity:

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  • No gum hypertrophy
  • No bleeding manifestation in buccal mucosa

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cont’d…

Abdomen:

Inspection:

shape of the abdomen:scaphoid

Flanks: not full

Umbilicus: centrally placed and inverted

Skin condition: normal

No visible peristalsis or pulsation

Hernial orifices: intact

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cont’d…

Superficial Palpation

  • Local temperature: normal
  • No tenderness
  • No rigidity

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Deep palpation

  • There is a mass in epigastric region ,9*7 cm size, non tender, firm in consistency, surface & margin irregular, mobile from side to side.
  • Succusion splash: absent

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Deep palpation:

  • Liver- Not palpable
  • Spleen- Not enlarged
  • Kidneys- Not ballotable
  • Both testes- normal

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Percussion:

  • Shifting dullness absent

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Auscultation

  • Bowel sound: present

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  • Other systemic examinations reveal no abnormality

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Salient feature

  • Akkas ajij, 60 years old, normotensive, non diabetic male hailing from cumilla presented with the complaints of recurrent bouts of fever followed by apyrexial period & persisted for 3-4 days,twice in a month for 4 months.
  • Fever was low grade,intermittent in nature, highest recorded temperature was 100 0 F, no h/o evening rise of temperature associated with drenching night sweat, relieved by taking antipyretics.

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  • He also complaints of a painless lump in upper abdomen for 4 months which is slowly increasing in size, painless.
  • He had no history of bleeding from any site.
  • His bowel and bladder habbit and sleep pattern is normal.

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Contd…

  • On general examination the patient was mildly anaemic, no jaundice, cyanosis, clubbing, koilonychias or leuconychia.
  • There was no palpable lymphadenopathy.
  • His pulse-80 b/min,BP-110/70 mm hg,Temparature-98F
  • There was no edema or sign of dehydration.

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Cont...

  • On systemic examination there is a epigastric mass ,about 9*7 cm, non tender, firm in consistency with irregular surface & iffegular margin, mobile from side to side.
  • No other organomegaly or ascites was found
  • There is no abnormalities in rest of the system.

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���What will be the diagnosis ?������?????

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Differential diagnosis

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  1. Abdominal Lymphoma (?relapse DLBCL)

2. Gastric Tuberculosis

3. ?Carcinoma of stomach

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Investigation profile:

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  • Gastric tissue biopsy(15/4/18)-Granulomatous gastritis ,histologically tuberculous.,
  • LN biopsy(12/9/18)-Granulomatous lymphadenitis,histologically consistent with tuberculosis
  • Biopsy from growth in gastric antrum(27/10/18)-Dx:Non Hodgkin lymphoma(D/D-Adenocarcinoma,porly differentiated)
  • CT abdomen(31/10/2018)
  • Comment:Diagnosed case of disseminated TB(Cat-1 treatment ongoing)
  • Soft tissue mass involving lower part of body,antrum & pyloric parts of stomach.
  • Hepatosplenomegaly.
  • IHC(24/11/18)-LCA ,CD20,CD79 alpha,Kappa,Lambda:Positive,Ki67-25%
  • Diagnosis:Diffuse large B-cell lymphoma

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Investigations:

CBC with ESR

April 22,2022

Haemoglobin

11.3 g/dl

ESR[ Westerngren method]

15 mm in 1st hour

Total wbc count

4.27x10^12/l

Total platelet count

470x10^9/l

Total wbc count

9x10^9/l

Neutrophil

54%

lymphocyte

38%

monocyte

5%

Eosinophil

3%

Basophil

0%

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Investigations ( cont’d…)

s.electrolytes

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sodium

137 mmol/l

potassium

4.7 mmol/l

chloride

99 mmol/l

T-co2

28.5mmol/l

LDH

141U/L

Calcium

2.5 mmol/l

creatinine

1.0mg/dl

ALT

40/L

Albumin

29 g/L

Uric acid

13.6 mg/dl

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USG of Whole Abdomen

  • Comments:

A bit coarse hepatic parenchyma

Splenomegaly

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CT abdomen(09/04/22)

  • Impression:post state of DLBCL
  • Present CT scan shows-
  • 1.Splenomegaly with multiple splenic SOLs-suggesting splenic infiltration.
  • 2.Diffuse wall thickening along greater curvature and antral part resulting huge proximal distension.

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Endoscopy of upper GIT(28/4/22)

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  • Oesophagus:Several columns of small sized varices seen at the lower part.
  • Stomach:Body & fundus showed evidences of severe congestive gastropathy.Mucosal irregularity with luminal narrowing seen involving lower body.Antrum appeared normal.
  • Duodenum:Bulb & post bulbar area normal.
  • Comment:Possibilities are:1.Carcinoma stomach 2.Gastric lymphoma with oesophageal varices with ?portal hypertensive gastropathy.

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Histopathology(30/4/22)

Specimen:Tissue from stomach

Microscopic examination:

Sections show gastric mucosa,granulation tissue & fibrinopurulent exudate.The mucosa shows dilated glands lined by foveolar type epithelium.The lamina propria contains moderate number of acute & chronic inflammatory cells.Focal intestinal metaplasia are also present.

  • Diagnosis: Chronic active gastritis with ulcer.

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