Case presented on 11th June, 2013 by Dr. Abu Jar Gaffar (MD Endocrinology Final part student) in the Department of Endocrinology, BSMMU

1. A middle aged man with severe
weight loss & increasing
breathlessness
Dr . ABU JAR GAFFAR
MD Final Part student
Department of Endocrinology
BSMMU

2. Patient Profile
• Mr. X
• 51 year
• Ex smoker
• farmer
• D/A : 01/06/13

3. Presenting Complaints
• Cough & shortness of breath – 1 ½ yrs
• Swelling in front of the neck – 1 ½ yrs
• Swelling of both legs – 1 month

4. History of presenting complaints
Shortness of breath
 Start 1 ½ yrs back but increased for last 1 month
 Exertional
 Awakes from sleep at night
 associated with cough occassionally productive, scanty,
whitish with no haemoptysis
 no chest pain & having no seasonal variation

5. History of presenting complaints
• Swelling of both legs
progressive
reduced urine volume
associated with SOB & cough
no yellowish urine or sclera or haematuria

6. History of presenting complaints
• No H/O fever
• But significant weight loss of about 20 kg in last
1 and ½ years.

7. History of presenting complaints
• Diagnosed as a case of Graves thyrotoxicosis with heart
failure on December 2011 on basis of
Weight loss
heat intolerance
increasing bowel habit ( no blood, mucous,
tenesmus, normal in color & amount)
painless diffuse neck swelling
SOB, tender hepatomegaly, bilateral
leg edema &
Positive biochemical findings

8. • He was prescribed with carbimazole, captopril,
diuretics & was improving gradually.
• But he was on irregular follow up & stopped all
medications for last 3 months & subsequently
getting worse day by day

9. Other history
• H/O sudden severe chest pain on 2006 , got admitted in
NIDCH, diagnosed as primary spontaneous
pneumothorax ( lt), improved with tube thoracostomy
• No H/O TB or contact with TB patients.
• Ex smoker - 20 pack year
- Cessation of smoking for last 1 yr
due to his illness
- No h/o taking inhaler

10. No one in his family suffering from same type of
illness
Low socioeconomic

11. Physical examination

12. General Examination
• Anxious, cachectic
• Mildly anaemic non icteric
• Generalized lymphadenopathy involving lt anterior
cervical, Both supraclavicular & medial group of axillary
- largest in left axilla (3X2 cm)
- non tender, firm, discrete, mobile. No
discharging sinus
• Bil pitting leg edema

13. General Examination
• JVP : Raised
• Hands : warm, not sweaty, Fine tremor +
• Pulse : 88 bpm
• BP : 120/65 mm of HG
• RR : 24/min
• Temp : Normal

14. • Thyroid :
Enlarged, diffuse
soft, non tender, mobile
no retrosternal extension
thyroid bruit - present

15. Systemic examination
▫ Respiratory system :
▫ Barrel shaped chest
▫ Breath sound is vesicular with prolonged expiration
▫ Bilateral basal crackles
▫ No evidence of Pleural effusion

16. ▫ Abdomen :
• Liver is palpable 7 cm from right costal margin
along the right midclavicular line, firm, non-tender,
smooth surface, regular margin, upper border in rt 6th
intercostal space liver span 14 cm
• No Splenomegaly & ascites

17. Systemic examination
▫ Cardiovascular system
▫ Apex beat shifted in lt 6th
intercostal space, 12 cm
from midline, no gallop rhythm, no murmur
▫ Nervous system
▫ normal

18. Differential diagnosis
• Graves thyrotoxicosis with COPD with Heart failure
with disseminated TB
• Graves thyrotoxicosis with COPD with Heart failure
with lymphoma

19. Investigations

20. CBC
Date Hb TC DC ESR
31/01/12 10.5 gm/dl 65

21. • 30.05.13
FT4 7.15 ng/dl (0.8 – 1.5 ng/dl)
TSH 0.004 uIU/ml (0.35-5.8 uIU/ml)

22. • Chest Xray P/A ( 04.06.13):
Inhomogenous opacity with fibrotic band
shadows noted in upper & mid zone of Rt lung
field, calcification is in upper zone of rt lung
suggestive of sequlae of (rt) pul TB
Rt sided pleural reaction

23. 03.06.13
S. Albumin 30 gm/lt
S. Creatinine 0.7 mg/dl
S. Na 151, K 3.5, Cl 107, TCO2 25 mmol/L

24. • Reports awaiting
CBC
Tuberculin test
ECG, Echocardiogram
Spirometry
USG of W/A

25. Disseminated TB:
Points in favour Points against :
Wt loss
Generalized
lymphadenopathy
Radiographic change
hepatomagaly
Weight loss & lymphadenopathy
may be due to Graves disease
No fever
Lymh nodes are not matted
No ascites
No H/O contact with TB patients

26. Lymphoma
Points in favour Points against :
Severe weight loss
Generalized Lymphadenopathy
Lymphnodes are not rubbery
No spenomegaly , ascites

28. Problems
• Diagnostic dilemma
• Is it necessary to perform any more further
investigations to reach the diagnosis?
• What will be the further management?