“A 51 year old male with ascites and generalized lymphadenopathy”

Theo Ntenegi

Continuing Medical Education Announcement

Harvard Medical School

RSS 3081: Monthly BOTSOGO Tumor Board; 2018-2019 Academic Year

Today’s Objectives:

•Describe the need for timely cancer case presentation and referral to treatment

•Formulate a multi-disciplinary plan for the care of common and complex oncologic cases

•Adopt successful, sustainable strategies to mitigate barriers to quality cancer care common in resource constrained environments

Target Audience:

Oncologists, internists, surgeons, radiation oncologists, infectious disease specialists, nurses, physicists, therapists, technicians, research staff, administrators, policy makers.

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This activity meets the criteria of the Massachusetts Board of Registration in Medicine for 1.0 credits of Risk Management Study

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Case Report

Patient: SN

Sex: Male

Age: 51

Address: Southern Botswana

Occupation: Free-lance builder

Case History (continued)

DOA: early 2018

Admitted to Male Medical Ward via outpatient clinic as a referral from hospital outpatient department.

Presenting Complaints

1. Abdominal Swelling

Since late 2017, worsening since early 2018.

Associated with diffuse pain.

No bowel movement changes.

No Hx of Melena

Presenting Complaints (continued)

2. Pedal Oedema

Onset early 2018

Bilateral with no alleviating factors.

Presenting Complaints (continued)

3. Lymphadenopathy

Noticed in neck area, since late 2017

More noticed in Groin area and underarms in early 2018.

Gradually increasing in size and number.

Painless

None ruptured.

Past Medical History

Weight loss noted since 2017.

On and off fevers noted prior to presentation.

No night sweats.

No chronic cough.

Past Medical History

RVD Negative (HIV negative)

No Known Co-Morbidities

No chronic medications

No Hx. of TB treatment

No Hx of STD treatment

No Hx. of Hospital admission

Past Medical HistorySeen in health facilities several times before current presentation:

• early 2018: Local Clinic – Tonsillitis and neck swelling > Given ABX.

• 2018: Local Clinic - Tonsillitis

• 2018: Local Clinic – Tonsillitis and neck swelling

• 2018: Local Clinic – UTI, Inguinal Lymphadenopathy

• Mid-2018: Local Clinic – Abdominal pain and distension > referred to hospital

• Mid-2018: Hospital –Abd. Ultrasound -Hepatomegaly +Ascites > Referred to PMH.

Personal, Social and Family History

Significant Drinking history >30 years. 6 – 10 units daily.

Significant Smoking history +/- 10 pack years.

No history of work in the mines

Family history negative for malignancy.

Physical Examination

Chronically ill looking, poorly nourished with abdominal distention and multiple masses on the neck region.

Finger clubbing + (grade 3)

No jaundice

Resp: Reduced Air Entry+ Stony dull (left lower)

CVS: Normal findings

Abd: ++Ascites, Firm Hepatomegally (span 16)

No signs of encephalopathy

Physical Examination

Generalised-Bilateral lymphadenopathy, Non-matted, Size – (0.3 – 3+cm)

Involving:

- Cervical - Axilar

- Submandibular - Antecubital

- Pre + Post Auricular - Inguinal

- Occipital - Popliteal

- Supraclavicular

Admission diagnosis

1. Chronic live disease with portal HTN

2. Disseminated TB Vs. Lymphoma

Progress In the Ward

Day 4:

CXR- Left Pleural Effusion, no lesions noted.

Paracentesis and Pleural Tap.

Day 9:

Abd. Ultrasound – Ascites, Homogeneous Hepatomegally with no focal lesions. +Pleural Effusion. Mild homogeneous Spleenomegally. +Paraaortic Lymphadenopathy. No Pericardial Effusion.

Day 11:

Ascetic Fluid : SAAG> 11g/dL, Cell Count -60; 80% Lymphocytes. No Malignant cells. Nillbacterial growth.

Pleural Fluid: Exudative.

Pathology

LN Biopsy done (cervical) – Reported on day 31

– LN with fibrotic thickened capsule and total architectural effacement. Tumour with mixed reactive component including plasma, lymphocytes, plasma cells, neutrophils and histocytes.

– Features favouring Hodgkin Lymphoma – Nodular Sclerosing Type.

– Histologically and immunohistochemically consistent with Hodgkin Lymphoma.

Pathology

Pathology

Pathology

Pathology

Pathology

Pathology

Day 24:

OGD- Early lower eosophageal varices.

Day 32:

Oncology review.

Requested CT Head, chest, abdo, pelvic.

To be initiated on chemo and refered to chemo clinic.

Day 35:

Developed Confusion – encephalopathy (GCS 14/15)

Became Septic (febrile, confused, tachypnoec)

Transferred to High dependency cubicle and septic workup initiated.

Started on Meropenem.

Oncology r/v requested.

Day 38:

Oncology Review

Septic, GCS 11/15, Left Pleural Effusion.

Not for any Oncological treatment.

Oncology request review once medically fit –suggested palliative care.

Day 45: Death Notification

Chest X-ray: on admission

Chest x-ray: during admission

A 51 year Male, RVD Negative (HIV negative) Presenting with Generalised Lymphadenopathy, ascites and hepatomegally.

Final Diagnosis: Advanced Nodular SclerosingHodgkin Lymphoma. Stage III2 (Modified Ann Arbor – Cotswold)

Investigations Reference Ranges

20/08/2018 23/08/2018 30/08/2018 03/09/2018 10/09/2018

WCC 4-10 9.44 8.55 8.3 8.2HB 12-15 10.6 11.1 12.8 12.3MCV 83-99 93.8 92.9 94.6 94.5PLTS 150-400 264 270 325 224Neut 2-7.0 5.0 5.1 5.1 5.6Lymph 1.0-3.0 1.5 1.1 1.1 1.0Eosino 0.02-0.5 0.2 0.0 0.18Na+ 135-145 130 126 132 125K+ 3.5-5.1 4.16 3.96 4.4 6.6Urea 2.0-7.0 2.5 3.2 4.1 4.08Creat 53-97 36 34 35 32Ca 2.2-2.6 2.01Mg 0.6-1.10 0.69Phos 0.8-1.55 1.12Tot Prot 60-80 61.2 78.4 55.2 59 58.2Tot Bil 1.0-25.7 11.6 7.68 13.6Conj Bil 0-3.0Albuim 35-55 23.9 22.7 25.7 21.8ALP 35-110 183 153 170 205GGT 11-50 172 169 193 240 229ALT 11-40 9.1 7.8 6.0 5.3 10AST 10-34 32.8 26.8 27 34 34LDH 210-425 205 211INR 1.21 1.4APTT 25-45 29.6 32.8 33

Hasenclever Score

Hasenclever Score

Score 0 1 Patient’s Score

Serum albumin Normal <40 g/L 1

Haemoglobin >10.5 g/dL <10.5 g/dL 0

Age <45 >45 1

Sex Female Male 1

Stage <IV IV 0

Leucocytosis <15x109/L >15x109/L 0

Lymphopenia >0.6x109/L <0.6x109/L 0

Cumulative Score 3

Discussion

Approach to a patient with suspected Hodgkin Lymphoma.

Criteria for Chemotherapy fitness.

Staging Hodgkin Lymphoma.

Preparation and Investigations prior to Oncology referral.

Questions

What can be done to promote early diagnosis of treatable malignancy in Botswana.

Are there any investigations that can be done in peripheral health facilities to support early Diagnosis of Malignancy.

What strategies can we put in place to train new doctors on how to send samples for investigation to the National Health Lab.

Available investigations in PMH.