Case discussion Case discussion Dr. Neena Mampilly, MD

Senior Consultant

Baby Memorial Hospital

Kozhikode

IAPM Kerala Chapter June 2020

Case 1

• 45 yr male

• H/O swelling left upper cervical level IIb

• No fever, pain, dysphagia

• Treated case of Koch’s adenitis 6 months back• Treated case of Koch’s adenitis 6 months back

• General examination and systems: WNL

• Routine blood investigations : WNL

Cervical lymph node biopsy

• Lymph node 4x3x3cm

• Cut section fleshy

Case 2

Clinical history

• 19 yr male

• C/O left submandibular swelling of 6 months duration, increased in size since 1 month

• No H/O fever/ weight loss• No H/O fever/ weight loss

Clinical examination

• General condition fair

• No pallor/ edema/ icterus

• Swelling left submandibular region 3.5 cm

• No other lymph nodes palpable• No other lymph nodes palpable

• No organomegaly

Investigations

• Complete Blood Count

• Hb 15.4g%

• Total count 8700/cmm; N 50%, L 40%, E 7%, M 3%

• Platelets 2.5 L/cmm

• Blood urea 21mg/dl• Blood urea 21mg/dl

• S. Creatinine 0.9 mg/dl

• S. uric acid 7.3 mg/dl

• LFT WNL

• LDH 156

• Peripheral smear WNL

• HIV/ HBsAg Negative

• Left submandibular lymph node biopsy

• Grossly , lymph node mg 3cm/3cm/3cm. Cut section uniform fleshy whitesection uniform fleshy white

Case 3

• 11 yr male

• C/O fever 1 month

• Swelling in back and thigh 1 week

• No h/o significant illness in the past• No h/o significant illness in the past

• O/E, 2.5x2.5cm swelling (R) infrascapular region, 1.5x1.5cm swelling (R) preauricular region, 1x1cm swelling anterolateral region of (R) thigh

• Systemic examination : WNL

• Blood investigations: WNL

• Trucut biopsy from chest wall lesion and thigh lesionlesion

Case 4

Clinical history

• 28 yr lady

• C/O high grade fever 1 week

• Toothache and generalised tiredness

• O/E cervical lymph nodes• O/E cervical lymph nodes

• Splenomegaly

• CVS, CNS, RS , WNL

Investigations

• Hb 12, TC 6.6(N60,L38,E2)

• Plt 110K

• ESR 28

• S.Creat 0.6• S.Creat 0.6

• Na 135,K 4.3

• Urine RE : wnl

• CXR : normal

• TB 0.9, SGPT 274, SGOT 296

• ALP 444,TP 7.2(3.5/3.7)

Investigations…

• Hb 10/TC 2.6K/Plt 47K

• ESR 36

• S creat 0.5

• SGPT 151(274)• SGPT 151(274)

• Cultures Sterile

• Rpt CXR no patch

• S Ferritin 1300/ TG 267

• ANA : Neg.

Peripheral smear

• Dengue Ab : Neg.

• Leptospira Ab : Neg.

• Rickettsial Ab : Neg.

• Malaria Card : Neg.

• Rpted Thick smear• Rpted Thick smear

for MP : Neg.

Hepatitis markers : Neg.

Typhi fast Positive

Widal Negative

Clinical differentials

• Dental abscess

• Viral syndrome

• Enteric fever

• Malaria• Malaria

• Rickettsial fever

USG Abdomen

• Liver mildly enlarged

• Acute hepatic parenchymal disease

• Splenomegaly

• Upper abdominal lymphnodes• Upper abdominal lymphnodes

• Fever persisting

• Tachycardia

• Rpt Cultures negative

• 2D Echo to R/O IE• 2D Echo to R/O IE

• S ferritin 3966(1361)

• TG 389(267)

• Bicytopenia

• Bone marrow showing histiocytosis with hemophagocytosis

Clinical diagnosis

• Hemophagocytic Lymphohistiocytosis(HLH)

• Cervical lymph node biopsy