Big Problem On the Neck   Dr.Pradeep Johnson Mentor : Dr.Varuguna Pandian
Chief Complaints <ul><li>A 49 year old female presented with complaint  of swelling right side of neck 9 month duration. <...
H/O  Presenting Illness <ul><li>Patient noticed swelling 9 months back on the right side of the neck. </li></ul><ul><li>6 ...
H/O Past Illness <ul><li>PLHA since 12/01/2009 with base line CD4 count 142 </li></ul><ul><li>H/o  ATT 2 years back 6 mont...
Family History <ul><li>Parents – Natural death </li></ul><ul><li>Siblings – Healthy as per patient </li></ul><ul><li>Husba...
Personal History <ul><li>House wife maintains personal and common hygiene </li></ul><ul><li>Denies extra marital/ pre mari...
Treatment History <ul><li>On CTZ Prophylaxis since Jan 2009. </li></ul><ul><li>CAT 1 ATT completed 6 months in 2007 for PT...
General Examination <ul><ul><li>Patient conscious, stable, afebrile, moderate built. </li></ul></ul><ul><li>No  Pallor  </...
Systemic Examinations <ul><li>CVS  : Apex beat normal in position </li></ul><ul><li>S1 S2 audible, No added sounds </li></...
Vital Signs <ul><li>BP  : 110/70 mm Hg </li></ul><ul><li>Pulse  : 80/min </li></ul><ul><li>Temperature  : Normal </li></ul...
UGS Abdomen & Pelvis <ul><li>Normal Study </li></ul>
 
 
 
Local Examination <ul><li>Hard immobile enlarged lymph node right side of neck occupying pre auricular / right mandible/po...
Summary <ul><li>A 49 yr old female PLHA since Jan/2009,on CTZ prophylaxis with base line CD4 142 cells, past H/o ATT 6 mon...
 
 
 
Investigations <ul><li>CBC </li></ul><ul><li>RBS </li></ul><ul><li>LFT </li></ul><ul><li>RFT </li></ul><ul><li>Sputum AFB ...
Test Results <ul><li>HB  9.6  g/dl </li></ul><ul><li>WBC  2.0  10 x cu mm </li></ul><ul><li>RBC  3.94  10 x cu mm </li></u...
Test results cont…. <ul><li>BILIRUBIN  0.4  mg/dl </li></ul><ul><li>SGOT  70  u/l </li></ul><ul><li>SGPT  36  u/l </li></u...
Differential Diagnosis?
Differential Diagnosis <ul><li>Solid tumor malignancies  </li></ul><ul><ul><li>Metastatic disease to lymph nodes secondary...
FNAC <ul><li>Microscopy : cellular smears studied show many large lymphocytes aggregate of histiocytes in a hemorrhagic ba...
Histopathology <ul><li>Specimen   :  Rt side of neck lymph node    biopsy </li></ul><ul><li>Impression  : Suggestive of ma...
Final Diagnosis <ul><li>PLHA Ann Arbor stage 1 lymphoma Rt side of neck WHO stage 4 </li></ul>
Discussion <ul><li>First HAART / Chemotherapy? </li></ul><ul><li>What are the merits and demerits in starting HAART first?...
HAART signicantly lowers risk of non-Hodgkin's lymphoma for up to ten years, regardless of nadir CD4 count  <ul><li>They f...
Chemotherapy <ul><li>Chemotherapy first: </li></ul><ul><ul><li>Merits </li></ul></ul><ul><ul><ul><li>controls neoplastic c...
HAART <ul><li>HAART first </li></ul><ul><ul><li>Merits  </li></ul></ul><ul><ul><ul><li>Increased immunity against neoplast...
Types lymphoma <ul><li>T- cell lymphoma </li></ul><ul><li>B- cell lymphoma </li></ul><ul><li>B- cell lymphomas are 10 time...
 
High Grade NHL <ul><li>Diffuse large B-cell lymphoma </li></ul><ul><li>Adult T-cell leukaemia / lymphoma </li></ul><ul><li...
Stages and Prognosis
Courtesy : www.lrf.org.uk
Courtesy : www.lrf.org.uk
TREATMENT <ul><li>Chemo-therapy </li></ul><ul><li>Radio-therapy </li></ul><ul><li>Stem cell transplantation </li></ul><ul>...
Chemo-therapy <ul><li>Two of the most common combinations are 'CHOP' and 'CVP‘. 'CHOP' is a combination of three chemother...
Stem cell Therapy Courtesy: www.cancercouncil.com.au
Marine Treasure
<ul><li>Sea Vegetables helps in treatment and prevention of neoplasm? </li></ul>
Sea Vegetables <ul><li>Classified by pigment composition </li></ul><ul><li>- Blue algae  (rocks) </li></ul><ul><li>- Green...
 
 
Teas J ,  Hebert JR ,  Fitton JH ,  Zimba PV . Health Promotion Education and Behavior, The Norman J Arnold School of Publ...
 
 
 
ACKNOWLEDGEMENTS <ul><li>The Superintendent , GHTM </li></ul><ul><li>Medical Director, I TECH </li></ul><ul><li>RMO, GHTM ...
<ul><li>Thank YOU ! </li></ul>
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Monstering Humans.Ppt 2003

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The Disease which made Humans look like monsters.

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Monstering Humans.Ppt 2003

  1. 1. Big Problem On the Neck Dr.Pradeep Johnson Mentor : Dr.Varuguna Pandian
  2. 2. Chief Complaints <ul><li>A 49 year old female presented with complaint of swelling right side of neck 9 month duration. </li></ul>
  3. 3. H/O Presenting Illness <ul><li>Patient noticed swelling 9 months back on the right side of the neck. </li></ul><ul><li>6 months in the size of 25 paisa coin in diameter. </li></ul><ul><li>Took traditional medicine and noticed rapid increasing swelling in the past 3 months. </li></ul>
  4. 4. H/O Past Illness <ul><li>PLHA since 12/01/2009 with base line CD4 count 142 </li></ul><ul><li>H/o ATT 2 years back 6 months completed. </li></ul><ul><li>On CTZ prophylaxis since Jan 2009. </li></ul><ul><li>No H/o Diabetes, Hypertension, Jaundice. </li></ul><ul><li>No H/o other OI’S. </li></ul>
  5. 5. Family History <ul><li>Parents – Natural death </li></ul><ul><li>Siblings – Healthy as per patient </li></ul><ul><li>Husband had swelling right neck size of an egg treated with chemo therapy. </li></ul><ul><li>Two children 1 male and 1 female HIV negative </li></ul>
  6. 6. Personal History <ul><li>House wife maintains personal and common hygiene </li></ul><ul><li>Denies extra marital/ pre marital sexual contacts. </li></ul><ul><li>Married since 30 yrs </li></ul>
  7. 7. Treatment History <ul><li>On CTZ Prophylaxis since Jan 2009. </li></ul><ul><li>CAT 1 ATT completed 6 months in 2007 for PT. </li></ul><ul><li>3 months back took traditional medicine for right neck swelling. </li></ul>
  8. 8. General Examination <ul><ul><li>Patient conscious, stable, afebrile, moderate built. </li></ul></ul><ul><li>No Pallor </li></ul><ul><li>Cyanosis </li></ul><ul><li>Clubbing </li></ul><ul><li>Icterus </li></ul><ul><li>Koilonychia </li></ul><ul><li>odynophagia / dysphagia / Breathing difficulty </li></ul><ul><li>Pedal Edema </li></ul><ul><li>Neurological deficit, Higher mental functions normal </li></ul><ul><li>Oral cavity – NAD </li></ul><ul><li>Hard immobile swelling on the right side of neck. </li></ul>
  9. 9. Systemic Examinations <ul><li>CVS : Apex beat normal in position </li></ul><ul><li>S1 S2 audible, No added sounds </li></ul><ul><li>RS : Trachea mid line </li></ul><ul><li>NVBS </li></ul><ul><li>No raised JVP </li></ul><ul><li>P/A : Soft, No organomegaly </li></ul><ul><li>CNS : NAD </li></ul>
  10. 10. Vital Signs <ul><li>BP : 110/70 mm Hg </li></ul><ul><li>Pulse : 80/min </li></ul><ul><li>Temperature : Normal </li></ul><ul><li>Height : 165 cm </li></ul><ul><li>Weight : 65 kg </li></ul><ul><li>BMI : 19 </li></ul>
  11. 11. UGS Abdomen & Pelvis <ul><li>Normal Study </li></ul>
  12. 15. Local Examination <ul><li>Hard immobile enlarged lymph node right side of neck occupying pre auricular / right mandible/posterior mid line of neck/ till right clavicle and right trapezium. </li></ul><ul><li>Non tender </li></ul><ul><li>No warmth </li></ul>
  13. 16. Summary <ul><li>A 49 yr old female PLHA since Jan/2009,on CTZ prophylaxis with base line CD4 142 cells, past H/o ATT 6 months completed 2 yrs back. Presented with c/o swelling Rt side of neck 9 months duration, rapid increase in swelling past 3 months,H/o traditional medicine 3 months back. </li></ul>
  14. 20. Investigations <ul><li>CBC </li></ul><ul><li>RBS </li></ul><ul><li>LFT </li></ul><ul><li>RFT </li></ul><ul><li>Sputum AFB </li></ul><ul><li>Mantoux Test </li></ul><ul><li>X-ray chest PA view </li></ul>
  15. 21. Test Results <ul><li>HB 9.6 g/dl </li></ul><ul><li>WBC 2.0 10 x cu mm </li></ul><ul><li>RBC 3.94 10 x cu mm </li></ul><ul><li>RBS 113 mg/dl </li></ul><ul><li>UREA 14 mg/dl </li></ul><ul><li>CREATININE 0.7 mg/dl </li></ul><ul><li>AMYLASE 126 u/l </li></ul><ul><li>PROTIEN TOTAL 8.5 g/dl </li></ul><ul><li>ALBUMIN 3.1 g/dl </li></ul><ul><li>GLOBULIN 5.4 g/dl </li></ul>
  16. 22. Test results cont…. <ul><li>BILIRUBIN 0.4 mg/dl </li></ul><ul><li>SGOT 70 u/l </li></ul><ul><li>SGPT 36 u/l </li></ul><ul><li>ALK PHOSPHATASE 135 u/l </li></ul><ul><li>MANTOUX NEG </li></ul><ul><li>SPUTUM AFB NEG </li></ul><ul><li>(3 smears) </li></ul><ul><li>LDH 270 u/l </li></ul>
  17. 23. Differential Diagnosis?
  18. 24. Differential Diagnosis <ul><li>Solid tumor malignancies </li></ul><ul><ul><li>Metastatic disease to lymph nodes secondary to carcinoma, melanoma, or sarcoma </li></ul></ul><ul><li>Other hematologic malignancies or lymphoproliferative disorders </li></ul><ul><ul><li>Granulocytic sarcoma </li></ul></ul><ul><ul><li>Multicentric Castleman disease </li></ul></ul><ul><li>Benign lymph node infiltration or reactive follicular hyperplasia secondary to infection (eg, tuberculosis; other bacterial, fungal, and, rarely, viral infections), and collagen-vascular diseases </li></ul>
  19. 25. FNAC <ul><li>Microscopy : cellular smears studied show many large lymphocytes aggregate of histiocytes in a hemorrhagic back ground. </li></ul><ul><li>Impression : Suggestive of lympho-proliferative disorder </li></ul><ul><li>Done 3 months back at SALEM </li></ul>
  20. 26. Histopathology <ul><li>Specimen : Rt side of neck lymph node biopsy </li></ul><ul><li>Impression : Suggestive of malignant round cell tumor Rt side of neck lymph- node biopsy </li></ul><ul><li>Comments : Non-Hodgkins lymphoma </li></ul>
  21. 27. Final Diagnosis <ul><li>PLHA Ann Arbor stage 1 lymphoma Rt side of neck WHO stage 4 </li></ul>
  22. 28. Discussion <ul><li>First HAART / Chemotherapy? </li></ul><ul><li>What are the merits and demerits in starting HAART first? </li></ul><ul><li>Could we start HAART/Chemotherapy simultaneously? </li></ul><ul><li>Comment on treat OI first and Initiate HAART? </li></ul>
  23. 29. HAART signicantly lowers risk of non-Hodgkin's lymphoma for up to ten years, regardless of nadir CD4 count <ul><li>They found that the highest incidence of non-Hodgkin’s lymphoma (13.6 per 1000) took place in the pre-HAART era (1993-1995). During the period, 2002-2006, the incidence declined to a low of 1.8 per 1000. </li></ul><ul><li>Thus,” they conclude, “although it was already clear that HAART prevents [non-Hodgkin’s lymphoma] through improvement of immune status , this study shows that HAART avoids the majority of [non-Hodgkin’s lymphoma], even among the most severely immunosuppressed individuals.” </li></ul><ul><li>Reference Polesel, J et al. Non-Hodgkin’s lymphoma incidence in the Swiss HIV Cohort Study before and after highly active antiretroviral therapy. AIDS 22(2), 301-306, 2008 . </li></ul>
  24. 30. Chemotherapy <ul><li>Chemotherapy first: </li></ul><ul><ul><li>Merits </li></ul></ul><ul><ul><ul><li>controls neoplastic cell division, </li></ul></ul></ul><ul><ul><ul><li>tolerance to ART may be improved </li></ul></ul></ul><ul><ul><li>Demerits </li></ul></ul><ul><ul><ul><li>delay the initiation of ART </li></ul></ul></ul><ul><ul><ul><li>higher risk of other OI </li></ul></ul></ul><ul><ul><ul><li>risk of IRIS (once started on ART) </li></ul></ul></ul>
  25. 31. HAART <ul><li>HAART first </li></ul><ul><ul><li>Merits </li></ul></ul><ul><ul><ul><li>Increased immunity against neoplastic antigen </li></ul></ul></ul><ul><ul><li>Demerits </li></ul></ul><ul><ul><ul><li>intolerance </li></ul></ul></ul><ul><ul><ul><li>Low or non adherence </li></ul></ul></ul>
  26. 32. Types lymphoma <ul><li>T- cell lymphoma </li></ul><ul><li>B- cell lymphoma </li></ul><ul><li>B- cell lymphomas are 10 time common than T-cell lymphoma </li></ul>
  27. 34. High Grade NHL <ul><li>Diffuse large B-cell lymphoma </li></ul><ul><li>Adult T-cell leukaemia / lymphoma </li></ul><ul><li>Anaplastic large T-cell lymphoma </li></ul><ul><li>Angioimmunoblastic lymphoma (AIL) </li></ul><ul><li>Burkitt’s lymphoma </li></ul><ul><li>Enteropathy associated T-cell lymphoma </li></ul><ul><li>(Intestinal T-cell lymphoma) </li></ul><ul><li>HIV and AIDS related lymphoma </li></ul><ul><li>Intestinal T-cell lymphoma </li></ul><ul><li>Lennerts lymphoma </li></ul><ul><li>Lymphoblastic lymphoma </li></ul><ul><li>Mantle cell lymphoma </li></ul><ul><li>Mediastinal diffuse large b-cell lymphoma </li></ul><ul><li>Nasal type T – cell lymphoma </li></ul><ul><li>Peripheral T-cell lymphoma </li></ul><ul><li>Primary central nervous system lymphoma </li></ul>
  28. 35. Stages and Prognosis
  29. 36. Courtesy : www.lrf.org.uk
  30. 37. Courtesy : www.lrf.org.uk
  31. 38. TREATMENT <ul><li>Chemo-therapy </li></ul><ul><li>Radio-therapy </li></ul><ul><li>Stem cell transplantation </li></ul><ul><li>Steroid therapy </li></ul><ul><li>Biological therapy </li></ul><ul><li>Radio-immuno therapy </li></ul><ul><li>Complementary therapy </li></ul><ul><li>Courtesy: www.cancercouncil.com.au </li></ul>
  32. 39. Chemo-therapy <ul><li>Two of the most common combinations are 'CHOP' and 'CVP‘. 'CHOP' is a combination of three chemotherapy medications plus prednisolone, and stands for: </li></ul><ul><li>Cyclophosphamide </li></ul><ul><li>Hydroxydaunorubicin (also sometimes known as adriamycin or doxorubicin) </li></ul><ul><li>vincristine </li></ul><ul><li>Prednisolone </li></ul><ul><li>CVP', involves just cyclophosphamide, vincristine and prednisolone </li></ul>
  33. 40. Stem cell Therapy Courtesy: www.cancercouncil.com.au
  34. 41. Marine Treasure
  35. 42. <ul><li>Sea Vegetables helps in treatment and prevention of neoplasm? </li></ul>
  36. 43. Sea Vegetables <ul><li>Classified by pigment composition </li></ul><ul><li>- Blue algae (rocks) </li></ul><ul><li>- Green algae (shallow water) </li></ul><ul><li>- Brown algae (Intermediate depth) </li></ul><ul><li>- Red algae (deeper water) </li></ul><ul><li>Grow by photosynthesis </li></ul><ul><li>Fucoidan response for slippery and gluey nature of sea vegetables </li></ul><ul><li>Fucoidan – sulphated polysaccharide with glucose called “FUCOSE” </li></ul>
  37. 46. Teas J , Hebert JR , Fitton JH , Zimba PV . Health Promotion Education and Behavior, The Norman J Arnold School of Public Health, University of South Carolina and the South Carolina Cancer Center, 15 Medical Park, Suite 301 Columbia, SC 29203, USA. jane.teas@palmettohealth.org
  38. 50. ACKNOWLEDGEMENTS <ul><li>The Superintendent , GHTM </li></ul><ul><li>Medical Director, I TECH </li></ul><ul><li>RMO, GHTM </li></ul><ul><li>All Mentors, GHTM </li></ul><ul><li>Chief fellow </li></ul><ul><li>I TECH Faculty </li></ul><ul><li>Fellows </li></ul>
  39. 51. <ul><li>Thank YOU ! </li></ul>

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