1. Dr. Prarthana Kalgaonkar
Fellow in Pediatric Gastroenterology
Lokmanya Tilak Municipal Medical College
& General Hospital, Sion, Mumbai
Under guidance of- Dr. Alka Jadhav

2.  SM, a 10 year old female child, 3rd by
birth order, born of non consanguinous
marriage
 Chief complaints
• Fever
• Jaundice 8 days
• Cough - 5 days

3. Diagnosed as Hodgkin's disease in
2009. Completed 6 cycles of ABVD
chemotherapy in June 2010.
In November 2010, Post chemo PET
CT revealed no active disease and no
discrete nodal involvement
Admitted in October 2014, with above
complaints, found to have Lt pleural
effusion, s/o kochs & started on AKT.
H/o of multiple blood transfusions
during chemotherapy.
No h/o hemetemesis, melena,
abdominal distention, altered
sensorium.

4. Family history
• Mother –
Pott’s spine
• Elder sister-
HIV positive
& on ART
• Father -
Healthy
Birth History
● Not
significant
Immunization
• Not
vaccinated
for HBV
• Other
routine
vaccines
taken upto
B2
Developmental
History
●Normal

5.  Anthropometry
 Height - 128 cm (between -1SD to -2SD)
 Weight - 19.4 kgs (< 3rd SD)
 BMI - 12 ( <3rd SD) s/o SAM
 Vitals
 Normal
 General Examinations
 Pallor +,Clubbing grade 2, Icterus- ++, no
significant Lymphadenopathy.
 Scabetic rash +

6.  Inspection- NAD
 Palpation-
Liver- 7 cm : below RCM, span- 12 cm Firm in
consistency, non tender, rounded margins,
smooth surface.
Left lobe not palpable.
Spleen- 8 cm firm, non tender.
 Percussion- NAD
 Auscultation- NAD

7. Air entry decreased on left side
Vocal resonance decreased on left side
No adventitius sounds heard.
 CVS- NAD
 CNS- NAD

9. 20/10 3/11 11/11 18/11 22/11 24/11 26/11
S. Bil 4.4 3.2 1.6 7.7 12.4 6.8 3
Dir. Bil 2.1 1.1 0.5 4.3 8 3.2 1.1
AST 26 27 23 21 24 130 232
ALT 11 11 21 13 11 111 151
ALP 1230 1250 1126 1280 991 1039 787
T.
protein
6.6 5.7 6.8 6.1 6 6 6.1
albumin 3.6 3 3.9 3.3 3.1 3.2 3.3
 Complete Blood Count
Hb- 8.5 gm/dl
TLC- 23000/cmm
PS- normocytic hypochromic.
ESR- 68
Platelets- 325000/cmm

10.  HAV IgM - Negative
 Hepatitis B Markers
 HBsAg - Positive (in Oct 2014)
 HBeAg - Positive
 Anti Hbe - Negative
 HBc IgM - Not done
 HBc IgG total - Weakly Reactive
 HBV DNA PCR - > 20,000 IU/ml
 HCV - Non Reactive
 HIV - Non Reactive

11.  CXR: Left pleural effusion with no obvious infiltrates
 PLEURAL FLUID
 Total WBC – 910 cells/c.mm
 L – 90 %, P – 10 %
 Proteins- 3.1 gm %
 Cobweb present
 ADA- 16.8 %
 Cytospin- Negative for malignant cells
 Sputum for AFB x 3 : Negative
 MANTOUX test : Positive (10 mm)
 2D Echo: Thin rim of pericardial effusion

12.  USG ABDOMEN
 Retroperitoneal lymphadenopathy with homogenous
echotexture (non necrotic)
 Largest measuring 20 x 22 mm, round shape and
altered vascularity
 Hepatomegaly measuring 13 cm
 Focal hypoechoic hepatic lesions in left lobe
measuring 1.4 cm and 1.1 cm in size
 No portal nodes
 No ascites

13.  Hepatitis B infection – Acute / Chronic
 Hepatitis B infection with disseminated
Tuberculosis
 Hepatitis B infection with relapse Hodgkin’s

14.  PET CT:
 Metabolically active retroperitoneal and mediastinal
lymphnodes
 metabolically active splenomegaly
 focal hepatic lesions in the left lobe.
 Liver biopsy-
 Sclerotic and desmoplastic tissue showing diffuse
infiltration by distorted small lymphocytes and a few
large smudgy nuclei.
 No normal liver parenchyma included
 On immunohistochemistry, the occasional large atypical
lymphoid cells are positive for CD30,whereas they are
negative for CD20, CD3 and LCA

15. Hepatitis B and pleural effusion
secondary to tuberculosis in a relapse
of Hodgkin's disease .

16.  Dr. Mamta Manglani, Head of dept of
Pediatrics LTMMC and Incharge of the
Pediatric Haematology oncology unit LTMMC.
 Dr. Alka Jadhav, Professor pediatrics,
Incharge of division of pediatric
gastroenterology hepatology and nutrition.