Case history by a doctor<br />A 24 year old male presented with complaints of<br />Fever of 4 weeks duration <br />History...
h/o loss of appetite for the past 1 month<br />h/o loss of weight around 3-4 kilos over the last month<br />Past history<b...
Personal history<br />Known alcoholic  - occasional 3-4 drinks  twice a week<br />Not a smoker<br />No h/o any other addic...
Medical questions<br />Treatment history<br />Took antibiotics, anti-malarialsand antipyretics  for fever from a general p...
Clinical findings<br />General examination<br />Well built, moderately nourished<br />Febrile <br />No pallor<br />Not ict...
Vitals<br />Pulse 92 per minute<br />Blood pressure 126/80 mm hg<br />Respiratory rate 16/min<br />Temperature 101.8F<br />
Cardiovascular system:<br />Heart sounds S1, S2 heard, no murmurs <br />Respiratory system:<br />Normal vesicular breath s...
Diagnosis <br />Fever of unknown origin (FUO)<br />? Infectious<br />? Malignancy <br />
Investigations <br />ECG – sinus rhythm, WNL<br />CXR – normal<br />Hemogram<br />WBC 3,000<br />46% polymorphs, 48% lymph...
Random blood sugar 90mg/dl<br />Renal function tests:<br />Urea  24 mg/dl<br />Serum creatinine 0.9 mg/dl<br />Electrolyte...
Liver function tests:<br />Total bilirubin 1.2 mg/dl<br />Direct bilirubin 1.0 mg/dl<br />AST 45<br />ALT 46<br />GGT 67<b...
Blood group A+<br />Coagulation profile:<br />PT 14 sec<br />INR 1.0<br />aPTT 26 sec<br />Urine analysis <br />pH 6.5<br ...
Fever profile<br />Smear for malarial parasite – neg<br />Dengue IgM – neg<br />WIDAL neg 1 in 25 dilution<br />MSAT 2+<br...
TB screening:<br />Sputum AFB <br />Sample A – neg<br />Sample B – neg<br />Mantoux – neg<br />Chest x ray -  normal<br />...
Treatment <br />IVF for hydration<br />Tepid sponging<br />Antipyretics<br />Antibiotics  - 2 weeks<br />3rd generation ce...
With the above treatment  for two weeks the fever did not subside……<br />Common tropical infections (dengue, leptospirosis...
How to proceed?<br />What are the differential diagnosis considered in this patient? <br />
Approach to a patient with FUO<br />
Hematologist opinion<br />To rule out <br />CTD (connective tissue disorder);<br />Post viral adenopathy<br />LPD (lympho ...
Report:<br />CBC<br />TC 7,000<br />DC P68, L30, M2<br />Hb 10 g/dl<br />Platelets 180 000<br />ESR 25/55<br />Peripheral ...
Rheumatologist opinion:<br />Fever with lymphadenopathy<br />Suggested ANA, RF<br />To r/o connective tissue disorder<br /...
Evaluation of lymphadenopathy<br />Lymphadenopathy was an important clue, efforts were then directed towards evaluating th...
CT abdomen with contrast:<br />Liver normal in size<br />Spleen 10.3 x 4.3 cm -  normal<br />Para aortic region – multiple...
Incision biopsy of lymph nodeunder IV anesthesia:<br />0.5 x 0.3 cm lymph node architecture showing capsule with underlyin...
Comment on the lymph node biopsy… <br />
Lymph node biopsy report:<br />Non – specific lymphadenitis<br />
Fever for more than 3 weeks, evaluated for more than 1 week -FUO<br />CBC, differentials, peripheral smear, ESR, urine ana...
CT chest and abdomen with contrast<br />Multiple nodes in neck, mediastinum, abdomen. <br />Incision biopsy done<br />Biop...
? Empirical ATT<br />Empirical ATT was an attractive option but since the initial TB screen was negative we proceeded with...
Since the serology was not unambiguous we sought the opinion of the chest physician for empirical ATT<br />CT guided needl...
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Case description by a doctor

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no cause could be attributed for the symptoms. Incidentally ultra sonogram of the abdomen picked up peripancreatic lymphadenopathy. Patient was then referred to our institution for further evaluation

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Case description by a doctor

  1. 1. Case history by a doctor<br />A 24 year old male presented with complaints of<br />Fever of 4 weeks duration <br />History of presenting complaints<br />Fever was intermittent , associated with chills, no specific pattern<br />h/o diarrhea 4 weeks back which lasted for 2 days and subsided without treatment<br />
  2. 2. h/o loss of appetite for the past 1 month<br />h/o loss of weight around 3-4 kilos over the last month<br />Past history<br />Not a known diabetic<br />No h/o previous Anti Tuberculous Treatment<br />No h/o any drug intake<br />
  3. 3. Personal history<br />Known alcoholic - occasional 3-4 drinks twice a week<br />Not a smoker<br />No h/o any other addictions<br />Married 1 ½ years back, no kids, no pets<br />Employed at a vehicle repair shop<br />Family history<br />No family h/o malignancy or premature death<br />
  4. 4. Medical questions<br />Treatment history<br />Took antibiotics, anti-malarialsand antipyretics for fever from a general practitioner<br />Got admitted outside for the above complaints and was evaluated. But even after investigating for a week no cause could be attributed for the symptoms. Incidentally ultra sonogram of the abdomen picked up peripancreatic lymphadenopathy. Patient was then referred to our institution for further evaluation.<br />
  5. 5. Clinical findings<br />General examination<br />Well built, moderately nourished<br />Febrile <br />No pallor<br />Not icteric<br />No clubbing<br />No edema of extremities<br />Skin warm, dry, free of rashes<br />Cervical and inguinal nodes were palpable: 3-4 in number, bilateral, around 1.0- 1.5 cm in size, discrete, mobile, firm, non tender.<br />
  6. 6. Vitals<br />Pulse 92 per minute<br />Blood pressure 126/80 mm hg<br />Respiratory rate 16/min<br />Temperature 101.8F<br />
  7. 7. Cardiovascular system:<br />Heart sounds S1, S2 heard, no murmurs <br />Respiratory system:<br />Normal vesicular breath sounds heard, no added sounds<br />Abdomen:<br />Soft, no organomegaly<br />Nervous system:<br />No neurological deficits<br />
  8. 8. Diagnosis <br />Fever of unknown origin (FUO)<br />? Infectious<br />? Malignancy <br />
  9. 9. Investigations <br />ECG – sinus rhythm, WNL<br />CXR – normal<br />Hemogram<br />WBC 3,000<br />46% polymorphs, 48% lymphocytes, 6% eosinophils<br />Hemoglobin 10.5 g/l<br />Hematocrit 36<br />Platelet 220 000<br />ESR 20mm/hr<br />
  10. 10. Random blood sugar 90mg/dl<br />Renal function tests:<br />Urea 24 mg/dl<br />Serum creatinine 0.9 mg/dl<br />Electrolytes :<br />Na+ 136<br />K+ 4.0<br />Cl- 95<br />HCO3- 25<br />
  11. 11. Liver function tests:<br />Total bilirubin 1.2 mg/dl<br />Direct bilirubin 1.0 mg/dl<br />AST 45<br />ALT 46<br />GGT 67<br />SAP 149<br />Total proteins 7.6mg/dl<br />Albumin 4.2mg/dl<br />Globulin 3.4mg/dl<br />
  12. 12. Blood group A+<br />Coagulation profile:<br />PT 14 sec<br />INR 1.0<br />aPTT 26 sec<br />Urine analysis <br />pH 6.5<br />Specific gravity 1.025<br />Deposits 3-4/HPF<br />HbsAg - neg<br />Anti HCV - neg<br />
  13. 13. Fever profile<br />Smear for malarial parasite – neg<br />Dengue IgM – neg<br />WIDAL neg 1 in 25 dilution<br />MSAT 2+<br />Blood culture - no growth<br />Urine culture - no growth<br />HIV – negative<br />VDRL – non reactive<br />
  14. 14. TB screening:<br />Sputum AFB <br />Sample A – neg<br />Sample B – neg<br />Mantoux – neg<br />Chest x ray - normal<br />Ultrasonogram abdomen:<br />Liver 15 cm – mild hepatomegaly<br />Peripancreaticadenopathy<br />Paraaortic areas free<br />No free fluid<br />
  15. 15. Treatment <br />IVF for hydration<br />Tepid sponging<br />Antipyretics<br />Antibiotics - 2 weeks<br />3rd generation cephalosporin IV<br />Doxycycline oral<br />Antimalarial:<br />Quinine – 5 day course<br />
  16. 16. With the above treatment for two weeks the fever did not subside……<br />Common tropical infections (dengue, leptospirosis, malaria, filariasis, typhoid) being ruled out..<br />
  17. 17. How to proceed?<br />What are the differential diagnosis considered in this patient? <br />
  18. 18. Approach to a patient with FUO<br />
  19. 19. Hematologist opinion<br />To rule out <br />CTD (connective tissue disorder);<br />Post viral adenopathy<br />LPD (lympho proliferative disorder) – Hodgkin’s<br />Peripheral smear, CBC at hematology lab<br />
  20. 20. Report:<br />CBC<br />TC 7,000<br />DC P68, L30, M2<br />Hb 10 g/dl<br />Platelets 180 000<br />ESR 25/55<br />Peripheral smear<br />Normal study<br />Final opinion:<br />Review with AFB culture, lymph node biopsy.<br />
  21. 21. Rheumatologist opinion:<br />Fever with lymphadenopathy<br />Suggested ANA, RF<br />To r/o connective tissue disorder<br />ANA, RF turned out to be negative<br />
  22. 22. Evaluation of lymphadenopathy<br />Lymphadenopathy was an important clue, efforts were then directed towards evaluating the cause for lymph node enlargement<br />CT chest:<br />Mediastinaladenopathy, Supraclavicular adenopathy with one large node having intrathoracic extension.<br />
  23. 23. CT abdomen with contrast:<br />Liver normal in size<br />Spleen 10.3 x 4.3 cm - normal<br />Para aortic region – multiple small rounded and soft tissue density lesions with low attenuated center with peripheral enhancement on I.V. contrast encasing paraaortic region and aortocaval region suggestive of lymphadenopathy<br />
  24. 24. Incision biopsy of lymph nodeunder IV anesthesia:<br />0.5 x 0.3 cm lymph node architecture showing capsule with underlying lymphoid follicle composed of prominent germinal center, few follicles show polymorphous population of cells composed of lymphocytes , neutrophils and macrophages .<br />
  25. 25. Comment on the lymph node biopsy… <br />
  26. 26. Lymph node biopsy report:<br />Non – specific lymphadenitis<br />
  27. 27. Fever for more than 3 weeks, evaluated for more than 1 week -FUO<br />CBC, differentials, peripheral smear, ESR, urine analysis, LFT, RFT, Electrolytes, HIV, VDRL, serology- (dengue, lepto, typhoid), ANA, RF.<br />Blood culture, urine culture <br />Potential diagnostic clue- lymphadenopathy<br />Further evaluation directed towards it<br />
  28. 28. CT chest and abdomen with contrast<br />Multiple nodes in neck, mediastinum, abdomen. <br />Incision biopsy done<br />Biopsy inconclusive<br />? Empirical therapy<br />
  29. 29. ? Empirical ATT<br />Empirical ATT was an attractive option but since the initial TB screen was negative we proceeded with serology<br />Anti TB IgM – 0.41 < 0.8 negative<br />Anti TB IgA – 183 < 200 negative<br />Anti TB IgG – 505 > 225 positive<br />
  30. 30. Since the serology was not unambiguous we sought the opinion of the chest physician for empirical ATT<br />CT guided needle biopsy of the mediastinal node was advised<br />Bone marrow aspiration for AFB studies<br />

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