Winning CASE OF FEVER WITH LYMPHADENOPATHY, SPLENOMEGALY AND PANCYTOPENIA presented in ARMSCON 2014 , PGIMS Rohtak

1. CASE OF FEVER WITH
LYMPHADENOPATHY,
SPLENOMEGALY AND
PANCYTOPENIA
HISTORY
By : AAKANKSHA ARORA
42 years old male presents with
Chief complaints:
•Fever for 5 months
•Dull pain in left upper abdomen for 3 months
• Yellowish discoloration of eyes and urine for 1
month

2. HISTORY OF PRESENTING ILLNESS
 FEVER : 5 months; intermittent; high grade; no
diurnal variation ; associated with drenching night
sweats ;not ass with rigors and chills
 PAIN : 3 months ; insidious in onset ; dull &
persistent; mild in intensity ; no radiation; non
shifting ; dragging type; no aggravating and
relieving factors
 YELLOWISH DISCOLOURATION OF
EYES AND URINE: 1 month , insidious onset,
progressive
 H/O easy fatigability , weight loss , decreased
appetite
H/O of cough ,dyspnea

3. SYSTEMIC EXAMINATION
Hepatomegaly ; 1 cm below LCM in MCL ;non tender
splenomegaly ; 4 cm below LCM in MCL ; non tender
Rest of systemic examination was normal
Differential diagnosis
Infectious causes
Infectious mononucleosis
Tuberculosis
Malaria
Haematological causes
Hodgkin lymphoma
Non hodgkin lymphoma
Leukemia
Inflammatory causes
sarcoidosis
P/A
:

4. NO H/O bleeding from any site
NO H/O altered sensorium, dysuria,haematuria
PAST HISTORY : no h/o of blood transfusion, jaundice,
TB, DM
PERSONAL HISTORY : non alcoholic ,non smoker
FAMILY HISTORY: not significant
GENERAL PHYSICAL EXAMINATION
 BODY WEIGHT : 60 KG ; HEIGHT: 1.80m ; BMI:
18.5kg/m2
 Oriented to time ,place and person
 BP : 110/80 , HR : 134/min , temp : 103 deg. F ,
RR: 20/min
 P+ ,I+, Cl-, Cy- , PE-, JVP (N);LAP +
 MULTIPLE CERVICAL LN; discrete , firm ,rubbery,
non tender with largest one being of 2x2cm

5. LAB INVESTIGATIONS
Haemoglobin 8.0g/dl
TLC 3500/cmm
DLC 67/22/4/7
PLATELET
COUNT
59000/cmm
RBC COUNT 2.5million/cmm
ESR 64mm/hr
AST 45U/L
ALT 105U/L
T.BILIRUBIN 7.5g/dl
(Direct-
6.8g/dl)
ALBUMIN 3.5g/dl
LDH 417U/L
ALKALINE
PHOSPHATA
SE
247U/L
KFT NORMAL
PT ,PTT NORMAL
C-REACTIVE
5.5ng/dl
PROTEINS
BLOOD SUGAR 120mg/dl
SERUM ACE
LEVELS
NORMAL

6. PBF: Normochromic normocytic anaemia ,
eosinophilia , Thrombocytopenia
 Malaria blood film /QBC - negative
 Monospot test – negative
 WIDAL TEST -Negative
 SEROLOGY- hepatits B&C negative
 Sputum AAFB – negative
 Mantoux test- negative
DCT and ICT – negative
HIV –ELISA : Non reactive
RADIOLOGY : chest X-ray
bilateral hilar and mediastinal
Lymphadenopathy

7. USG abdomen
showing
enlarged para
aortic lymph
node
USG
abd
omen
showin
g
enlarge
d
spleen
CT SCAN of chest
showing
mediastinal
lymphadenopathy
No signs of portal
hypertension on CT
scan or USG
No focal lesions or
infarcts in spleen and
liver
CT Abdomen showing
enlarged spleen and
enlarged paraportal
lymph node

8. FNAC CERVICAL LYMPH NODE - POLYMORPHOUS CELL
POPULATION WITH RS LIKE CELLS IN BACKGROUND OF
LYMPHOCYTE ,EOSINOPHILS ,LYMPHOCYTES.
CERVICAL LYMPH NODE BIOPSY- PARENCHYMA EFFACED
WITH NODULES OF LYMPHOCYTES, EOSINOPHILS,
PLASMA CELLS WITH RS CELLS
BONE MARROW BIOPSY
TO RULE OUT THE CAUSE
FOR PANCYTOPENIA
Bone marrow infiltrated by nodules
formed of mixed population of cells-lymphocytes
,plasma cells
Neutrophils & eosinophils with RS
CELLS. Tumor infiltrated bone
marrow showed paucity of
haemopoeitic elements.
RS Cell

9. DIAGNOSIS
Presence of RS cells - PATHOGONOMIC of
HODGKIN LYMPHOMA
CONFIRMATION BY
IMMUNOHISTOCHEMISTRY –RS cells show
membrane positivity for CD15 and CD 30
ANN ARBOR STAGING: STAGE 4B
(involvement of bone marrow and cervical ,thoracic
and abdominal lymph node ass.with fever,night
sweats, weight loss)
TYPE: NODULAR SCLEROSIS

10. MANAGEMENT (6 cycles of ABVD)
ABVD(each cycle of 28
days include):
Doxorubicin 25 mg IV 1, 15day
Bleomycin 10mg IV 1, 15day
Vinblastine 6 mg IV 1,15day
Dacarbazine 375mg IV 1, 15day