2. Personal particulars
• 33 yrs/M
• Serving soldier
• Master in Computer Application (MCA)
• Resident of Delhi
• Informant Self
• Reliability good
2
3. • Immunesurviellence
– Onset – 2008
• Detected during evaluation of genital Herpes
– CD4 Profile :-
– Viral Load – 11152 copies/ul
3
Year CD4 Year CD4
Initial : 2008 287 cells/ul Aug 2014 313 cells/ul
Feb 2012 147 cells/ul May 2015 90 cells/ul
Aug 2012 345 cells/ul Aug 2016 40 cells/ul
Nov 2012 323 cells/ul Jan 2017 64 cells / ul
4. History of Present illness
• OIs
- Genitial Herpes
- Tubercular Lymphadenitis (Apr 2012)
Completed 9 months ATT
- Tenia Cruris
• Spouse – Retropositive on ART
• Children - Nil
4
5. – ART : ZLN (Apr 2012 with HRZE)
↓
TLE (DILI May 2012)
↓
Zidovudine + Lamivudine + Darunavir + Ritonavir +
Raltegravir (Sep 2016) due to viral and
immunological faliue
5
7. History of Present illness
• Fever – Low to Moderate grade
Associated with chills, No rigors
• Constitutional symptoms
• Night Sweats
• WEIGHT LOSS -
Not associated with cough, pain abdomen,
dysuria, vomiting, rash.
8. History of Present illness
• Weight Loss – 12 Kg in 04 months
• unintentional
• Reduced appetite
• Swelling in the neck Lt Rt
• Increasing in size over 3 weeks
• No h/o protrusion of eye, palpitation
• diarrhea, hyperhidrosis, intolerance to heat
• No h/o bone pain/ bleeding gums.
Swelling axillae/groin, abdominal fullness.
15. Summary
• 33 years old male, a case of
immunesurveillance with OIs of TB
Lymphadenitis and Genital Herpes ,on third
line ART presented with complaints of Fever,
Neck swelling and B symptoms of 4 months
duration
15
16. Gen examination
• Ht :168cm ,weight:56kg, BMI-19.84 Kg/m22
• P: 92/min, regular, normal volume and
character.
• BP: 126/80 mm Hg
• RR: 16/Min
• SPO2: 96% on
• Tenia Cruris, Genital Herpes
16
17. Gen examination contd.
• Pallor +
• B/L cervical LNE – 1.5 x 2 cm level IV & V firm,
matted, non tender, mobile
• Rt Axillary LNE : Medial Gp 1 x1 cm mobile.
• Rt Inguinal LN : 1.5 x 1 cm mobile
• No icterus, clubbing, cyanosis, oedema
17
18. Systemic examination
• P/A: Soft, non tender
– Spleen palapable 1 cm below LCM,
– Margins smooth
– Non tender
– Liver palpable 2 cm below RCM
– Non tender
– Margins smooth
– Span 15 cm
• Respiratory examination :
B/L air entry equal
18
20. Investigations
Parameter Patient Value Parameter Patient Value
Hb(gm/dl) 8.7 Urea/Creat(mg/dl) 13/0.65
TLC (cells /mm3)
16800 Na/K/Ca/Po4 (mEq/L) 132/4.20/7.50/4.20
DLC P65/L25 Bil(Tot/Dir) (mg/dl) 0.15/0.10
PLATELETS 3.7L TProt/Alb/Glob(g/dl) 7.20/3.0
ANC 10820 AST/ALT/ALP/LDH 22/32/88/331
PT/APPT/INR 12.6/29/1.07 Uric Acid 5.6
Urine C/S No growth CRP positive
URINE REME NAD HBsAg/Anti HCV Negative
Urine for Bile salt Negative DLCO/PFT Normal Study
B Sugar F/PP 80/101 S iron study/ TIBC Iron: 84, TIBC: 380
Dengue serology Negative CXR WNL
TORCH Negative ECG WNL
04/02/17
DEPARTMENT OF INTERNAL
MEDICINE
20
21. Investigation
• X Ray Chest :- NAD
• USG Abdomen (20/09/16) – Hepatosplenomegaly;
Retroperitoneal Lymphadenopathyl
• USG Neck (22/08/16) - B/L cervical Lymphadenopathy
• Bone Marrow Biopsy: Cellular reactive bone marrow. No
granulomas or lymphoma deposit seen
• Bone marrow Aspirate: Cellular bone marrow.
• ECG – WNL
22. Investigation
• USG Guided LN FNAC
– Rt Cervical LN.
– Zn stain negative
– Few scattered atypical cells with high NC ratio,
coarse chromatin and prominent large nucleoli –
Granulomatous Lymphadnitis
– Impression: Likely TB, adv excision biopsy
• Gene Xpert: MTB not detected,.
23. Investigation
• Excision Biopsy :
– Classical Hodgkin Lymphoma
– RS Cells with occasional binucluate and also
mono nuclear forms in a backgound of
lymphocyte / esoinophil
– CD30 positive, CD45 – Negative, CD15- Negative,
Pax- weakly positive, CD20- Negative, CD3-
Negative.
24. Investigation
• PET Scan : Metabolically active multiple
lymph nodes involving cervical axillary
supraclavicular, abdominal and pelvis
locations with mildly increased metabolic
activity of spleen
• Ann Arbor stage III B
27. Management
• Complications
– Mucositis
– Exacerbation of Tenia Cruris
– neutropenia (ANC-138)
- Managed with Neutropenia Precautions
- Inj GCSF
- Antibiotics
- Continue to be afebrile + counts improved
28. Management
• 2nd
cycle of Chemotherapy (3/11/16)
↓
- 1 episode of fever + vomiting
- + Febrile Neutropenia
- managed with antibiotics, GCSF and transfusion of Blood
component. (Blood culture negative)
29. Management
• 3nd
cycle of completed on 19/12/16
↓
– Recurrent infection on the form of Herpes
Genitals and multiple folliculitis
• Pus culture : Coagulase – Negative Staph
– MRSA sensitive to vancomycin
– NASAL Swab for MRSA : No growth
• Perianal Abscess
- Fissure in ANO
