diagnostic Dilemma about Tb

1. Central Case Presentation
Diseases With Access to All
Ages
May Not Always Present
Classically !!!

2. A 10 Year Old Boy With
Back Pain and Swelling
Dr Tanveer Kamal Fahim
Resident
Pulmonology , Phase B
Medicine Unit 4
NIDCH

3. Particulars of the patient
Master Shahid Ullah
Shahed
10 years
Student of class 6
Bikrampur , Munsiganj
Admitted in NIDCH on
11/3/19

4. Chief Complaints:
 Pain in the back for last 1 and ½ years
 Swelling in the back for same duration
 Cough for 15 days

5. History of Present Illness:
 Reasonably well 1 and ½ year back
 Since then, he is suffering from pain and
Swelling in the back

6. The Pain was
 Dull aching
 Localized in the back over the spine
 3/10
 Constant
 Non radiating
 Increased during posture change or
movement
 Partially relieved after taking Paracetamol

7. Bony swelling over the spine for same
duration
 Palpable
 Painless
 Hard
 Normal Temperature

8.  Labelled as a case of Spinal TB (Pott”s
Disease) on the basis of X ray Spine
 Started Anti TB CAT-on 31/10/17
 But did not improve Clinically

9. Pt developed cough 15 days back
 Productive
 Mucoid
 Amount less than 20 ml daily
 No diurnal variation
 Odorless
 Not blood stained

10. Also complained of occasional low
grade fever but no diurnal variation or
sweating or chills or rigor
No documentation of fever
Admitted into a Govt. Medical College
Hospital

11. Both cough and fever responded to
conservative treatment
Referred to NIDCH labelled as MDR-TB

12. Loss of appetite for last 1 and 1/2 year
Weight loss about 2 kg for last 1 and
1/2 year

14. History of Past Illness:
 Nothing significant

15. Family History :
 Lives with his parents and one sister
 All are in good health

16. Personal History
 Student of class 6

17. Socio-economic History
 Low-middle class family
 Monthly house hold income about 30
thousand taka

18. Treatment History
CAT - since 31/10/17
Antibiotics , can’t mention names
Paracetamol
Antiulcerant

19. Immunization History : Immunized
according to EPI schedule
Allergic History : Nothing significant

20. General Examination

21.  Ill – looking
 Mildly Anaemic
 Pulse : 90 beats/minute
 Temperature : 98 °F
 Respiratory rate :18 breaths/minute

22. Multiple lymph nodes are enlarged in
right posterior cervical chain and
axillary region in Right side
Variable size and shape
 Largest one is 2*2 cm in diameter
Firm consistency
Non tender
Some are matted some are discrete
Free from overlying skin or underlying
structures

23. Bony swelling over the spine
 2*2 cm diameter
 Oval
 Hard
 Non tender
 Fixed
 Temperature normal

24. Systemic Examination

25. Respiratory System Examination
Inspection : Normal
Palpation :
 Trachea : Central
 Apex beat: At left 5th
ICS just medial to mid
clavicular line
 Chest Expansion: Normal
 Vocal Fremitus: Normal

26. Percussion : Resonant
Auscultation :
 Breath sound : Vesicular
 Added sound : Absent
 Vocal resonance : normal

27.  Neurological System : No abnormality
detected
 Cardiovascular system : No abnormality
detected
 Gastro-Intestinal System : No abnormality
detected

28. What are the possibilities ??

29. Differential Diagnosis
 Disseminated TB
 Lymphoma
 Metastatic Malignancy

30. Investigations

31. CBC with ESR
23/10/17 23/10/18 3/3/19 12/3/19
Hb 11.8 10.0 9.2 9.8
ESR 100 25 115 70
TcWBC 12,000/cum
m
12,300/cum
m
14,200/cum
m
10000/cum
m
Neutrophil 75% 72% 80% 78%
Lymnphocyt
e
20% 20% 14% 11%
Monocyte 2% 5% 4% 9%
basophil 0 0 0 0
Platelet 368,000/cu
mm
361000/cum
m
270000/cum
m
MCV 31.2 62
MCHC 32 19
HCT 31.2% 29% 30%
RDW 15.6 18%

32. 12/3/19
RBS 40mg/dl
SGPT 41u/dl
S. Bilirubin 1 mg/dl
S. Creatinine 0.4 mg/dl
Sputum AFB Negative
Sputum C/S No growth
Sputum FAST Negative
3/3/19
S. LDH 325u/l (normally 120-300)
Sputum gene expert Negative

33. Chest X ray P/A view done on 25/10/2017

34. CXR P/A view done on 23/10/18

35. CXR P/A View on 23/2/19

37. MRI Spine

46. Chest CT scan done on 15/3/19

51. CT guided FNAC of left hilar mass:
Microscopic examination :
 Smears show monotonous population of
atypical lymphoid cells , small
lymphocytic type , many of them have
nuclear graving
 Background shows proteinaceious
material mixed with inflammatory cells

52. CT guided FNAC of left hilar mass:
Dx: Suggestive of Non Hodgkin Lymphoma

53. Excisional Biopsy of Cervical Lymph
node:
Report Pending

55. Final Diagnosis :
Non Hodgkin Lymphoma

56. Non – Hodgkin Lymphoma
 Monoclonal proliferation of lymphoid cells
of B-cell (90%) or T-cell (10%) origin
 Slight male excess
 Median age 65-70 years
 Most common – Diffuse Large B cell NHL or
Follicular NHL

57. High Grade NHL
 High proliferation rates
 Rapidly produces symptoms
 Fatal if untreated
 Potentially curable

58. Low Grade NHL
 Low proliferation rates
 May be asymptomatic for many
years/months
 Indolent course
 May be not curable

59. Clinical Features
 Often Widely disseminated at presentation,
including extranodal sites (bone marrow ,
gut , thyroid , lung , skin , brain , bone etc)
 Systemic upset : Weight loss , sweat , fever ,
itching common

60.  Lymphadenopathy
 hepatosplenomegaly
 Compression syndrome may occur - cord
compression , SVCO , ascities , gut
obstruction etc

61. Investigations
 CBC: may be Normal. ESR raised
 Chest X ray : mediastinal mass
 Liver function test
 Renal function test
 Uric acid level
 LDH

62.  CT scan of chest , abdomen , pelvis :
staging
 Positron Emission Tomography ( PET)
 Lymph node biopsy
 Bone marrow aspiration and Trephine
biopsy

63.  Immune phenotyping of surface
Antigen
 Cytogenetic analysis
 Immunoglobulin determination

64. Treatment
Low Grade NHL
 Asymptomatic patient : may not need
treatment – “ Watch and Waiting”
 Indication of treatment:
 Systemic symptoms
 Lymphadenopathy
 Marrow failure
 compression syndrome

65. Treatment options :
Chemotherapy:
Rituximub combined with
Cyclophosphamide,Prednisolone,Vincristine(R-
CVP) or
Cyclophosphamide,Prednisolone,Vincristine,D
oxorubicine (R-CHOP)or Bendamustine
Kinase inhibitor : Idelasib
HSCT
Radiotherapy : Rarely, stage 1 disease

66. High Grade NHL
 Chemotherapy : R-CHOP
(Cyclophosphamide,Prednisolone,Vincristi
ne,Doxorubicine) is first line therapy
 Radiotherapy: Stage 1 disease
 HSCT

67. Prognosis
 Low Grade NHL : Median survival -12 years
 Diffuse Large B cell NHL (High Grade)
treated with R-CHOP , 50% patient have
disease free survival of 5 years
 Patients under 65 years , HSCT improves
survival

68. Take Home message :
 Tuberculosis like presentation may not
always be Tuberculosis
 Bone erosion or collapse may not always
be bone tumor or pott’s Disease
 Routine follow-up and regular physical
examination is very important as
pathological findings may appear at late

69. Lets Pray For the Departed Souls of New Zealand Attack

70. Thank You All !!!