This document presents a case study of a 45-year-old male admitted with abdominal pain, loose stool, and weight loss. Examinations found left supraclavicular lymphadenopathy. Investigations revealed anemia, elevated inflammatory markers, abdominal lymphadenopathy and pancreatic masses. A biopsy of the cervical lymph node found diffuse high-grade non-Hodgkin lymphoma. A PET scan confirmed stage IV lymphoma with skeletal metastases. The confirmatory diagnosis was diffuse high-grade non-Hodgkin lymphoma. Treatment will be determined based on an oncologist's recommendation.

1. A S S A L A M U A L A I K U M
GOOD
MORNING

2. CASE
PRESENTATION
D R . G A Z I A Z I Z U R R A H M A N I M R A N
D E P T. O F M E D I C I N E

3. HISTORY
P E O P L E S A R E T R A P P E D I N H I S T O R Y A N D H I S T O R Y I S
T R A P P E D I N T H E M – J A M E S B A L D W I N

4. PARTICULARS
OF PATIENT
Name: Md. Zakir Hossain
Age: 45 years
Sex: Male
Occupation: Teacher
Present address: Mirpur-1
Permanent address: Bhola
Date of admission: 25.11.19
Date of examination: 25.11.19

5. PRESENTIING
COMPLAINTS

6. WHERE IS THE PROBLEM

7. HISTORY OF PRESENTING ILLNESS
• According to the patient‘s statement, he was
reasonably well 1 month back. Then he developed
recurrent diffused moderate abdominal pain which was
more marked in epigastric region, burning and
spasmodic in nature which radiate to back, aggravated
by taking food and worsened at night, partially relieved
by taking anti-ulcerants and by induced vomiting,
associated with bloating & heart burn.

8. • He also complained of persistent passage of small
amount of loose stool for last 22 days, frequency
about of 8-10 times per day, content was water and
partially digested food with no aggravating or
relieving factor and not associated with passage of
blood or mucus.

9. • He had no fever, night sweat or cough, but he loosed his
weight mildly during his illness.
• He had no history of dysuria, urgency or frequency.
• He is normotensive and nondiabetic.

10. • After that he consulted with a physician. After doing
investigation, USG W/A revealed abdominal
lymphadenopathy and multiple pancreatic masses.
FNAC from pancreas revealed granulomatous disease
with no caseation which suggested the pancreatic TB.
• So he was started Anti TB drug (4FDC), but despite of
taking drug properly for 22 days his condition was
deteriorating day by day.

11. PA S T H I S T O R Y
• He has no significant past history.

12. FAMILY HISTORY
• His all family members are healthy.

13. SOCIAL HISTORY
• He visited an active pulmonary tuberculosis patient
few days earlier.

14. PERSONAL HISTORY
• Nonsmoker
• Nonalcoholic

15. I BELIEVE YOU HAVE THOUGHT
SOMETHING ABOUT DIAGNOSIS

16. EXAMINATION
B Y E X A M I N I N G T H E T O N G U E O F T H E PAT I E N T A P H Y S I C I A N
F I N D O U T T H E D I S E A S E O F T H E B O D Y, A N D P H I L O S O P H E R S
T H E D I S E A S E O F T H E M I N D. – S T. J U S T I N M A R T Y R

17. GENERAL EXAMINATION
• Appearance: Ill looking
• Body built: Average
• Cooperation:
Cooperative
• Decubitus: On choice
• Anaemia: Absent
• Jaundice: Absent
• Cyanosis: Absent
• Clubbing: Absent
• Koilonychia: Absent
• Leukonychia: Absent

18. • BP: 120/80 mmHg
• Pulse: 74 b/min
• Temp: 98⁰F
• Respiratory rate: 18
br/min
• Lymph nodes: Left
supraclavicular
lymhadenopathy
• Thyroid: Not enlarged
• JVP: Not raised
• Bony tenderness: Absent
• Dehydration: Absent

19. LYMPH NODES EXAMINATION
Size:
variable
(largest:
3cm)
Shape:
Variable
Number:
Several
Consistency:
Firm
Fixity: free
from
underlying
structure
Matted
Temperature:
Normal
Tenderness:
Absent.
Margin:
Regular, ill
defined

20. ABDOMINAL EXAMINATION
•Inspection
–Size: Normal
–Shape: Normal
–Visible pulsation: No
–Visible peristalsis: No
–Engorged vain: No

21. ABDOMINAL EXAMINATION (CONTD…)
• Superficial Palpation
–Mild epigastric
tenderness
–Temperature: Normal
• Deep Palpation
–Organomegaly: Absent
–Tender epigastrium
–McBurney’s point tenderness:
Absent
–Murphy's Sign: Absent
–Lymph node: Not palpable

22. ABDOMINAL EXAMINATION (CONTD…)
•Purcussion
–Tympanic all over the
abdomen
•Auscultation
–Bowel sound: present
–Renal bruit: absent
–Borborygmi: present

23. OTHER SYSTEM EXAMINATION - NAD
Respiratory
System
Cardiovascula
r System
Nervous
System
Musculoskeletal
System

24. SALIENT FEATURE

25. • Md. Zakir Hossain, a 45-year-old normotensive,
nondiabetic male admitted in this hospital on 25.11.19
with the complaints of diffused recurrent spasmodic and
burning abdominal pain for 1 month which was more
marked in epigastric region which radiate to back,
aggravated by taking food, partially relieved by taking
anti-ulcerants and by induced vomiting, associated with
bloating & heart burn.

26. • He also complained of persistent passage of small
amount of loose stool for last 22 days, frequency about
of 8-10 times per day, content was water and partially
digested food with no aggravating or relieving factor
and not associated with passage of blood or mucus.
• He had no fever, night sweat or cough, but he loosed his
weight mildly during his illness.
• He had no urinary symptoms.

27. • After that he consulted with a physician. After doing
investigation, USG W/A revealed abdominal
lymphadenopathy and multiple pancreatic masses.
FNAC from pancreas revealed granulomatous disease
with no caseation which suggested the pancreatic TB.
• So he was started Anti TB drug (4FDC), but despite of
taking drug properly for 22 days his condition was
deteriorating day by day.

28. • On examination - Anaemia, Jaundice were absent. BP
120/80 mmHg, Pulse 78 b/min, Temp 98⁰F, Resp rate 18
br/min.
• There was Left supraclavicular lymphadenopathy of
several number with variable size and shape (largest:
3cm) with ill defined regular margin, nontender, firm in
consistency, matted and free from underlying structure
and overlying skin.

29. • Abdominal examination revealed tender epigastrium
with no other point tenderness or organomegaly.
• With normal other systemic examination findings.

30. PROVISIONAL DIAGNOSIS?

31. PROVISIONAL DIAGNOSIS
DISSEMINAT
ED
TUBERCULO
SIS
INVOLVING
ABDOMEN
AND LYMPH
NODES
PEPTIC
ULCER
DISEASE
GERD
ẽ ẽ

32. DIFFERENTIAL DIAGNOSIS?

33. DIFFERENTIAL DIAGNOSES
Lymphoma
Ca stomach
with metastasis
Ca pancreas Inferior MI

34. INVESTIGATIONS
N O M A N C A N H O P E TO F I N D O U T T H E T R U T H W I T H O U T
I N V E S T I G AT I O N . – G E O R G E R I C H A R D.

35. COMPLETE
BLOOD COUNT
• Mild anemia
• Mildly raised ESR
• Upper limit of T-WBC
• Lower limit of
Neutrophil
Lymphocytosis
• Normal RBC count
• Normal platelet count
28.10.201 25.11.19 Reference
value
Hb (gm/dL) 11.9 12.4 13-17
ESR (in 1st
hour)
35 20 0-10
T-WBC
(/cmm)
11,060 9,000 4000-
11000
Neutrophil
(%)
41 52 40-75
Lymphocyt
e (%)
55 42 20-40
RBC
(mill/cmm)
5.43 5.45 4.5-5.5
Platelet
(/cmm)
3,21,000 3,90,000 300000-
500000

36. PERIPHERAL BLOOD FILM
28.10.19
RBC Anisochromic with
anisocytic with
microcyte
WBC Mature with above
distribution
Platelets Normal
Comments Microcytic
hypochromic

37. GLUCOSE LEVEL
28.10.19
Plasma glucose
(mmol/L)
6.47
Corr. Urine suger Nil
2 hour after 75 gm
glucose (mmol/L)
9.26
Corr. Urine suger ++

38. BIOCHEMICAL REPORT
28.10.19 25.11.19 Refernence
value
S.
Creatinine
(mg/dL)
0.97 0.67 0.60-1.50
S. ALT (U/L) 16 <40
LDH (U/L) 436 120-246
CRP (mg/L) 17 <10
HBsAg Negative
Anti HCV Negative

39. X-RAY CHEST
•Normal
findings

40. ECG - NORMAL

41. ETT• Exercise capacity was
good.
• Positive hemodynamic
response to exercise.
• No significant ST
depression was seen
during exercise or
recovery period.
• Stress test is NEGETIVE
for ECG evidence of
provocable MI.

42. USG W/A @28.10.19

44. USG W/A @30.10.19

46. UPPER GI
ENDOSCOPY
•Erosion
seen in the
fundus,
body and
antrum of
stomach -
Gastritis

48. FNAC OF PANCREATIC MASS

49. USG OF
NECK
Suggestive of
supraclavicular
lymphadenopat
hy, larger one
most probably
infected matted
lymphadenopat
hy

51. CERVICAL LYMPH
NODE BIOPSY
PHOTOS FROM OT

52. CERVICAL LYMPH
NODE BIOPSY
Diffuse high grade aggressive Non-
Hodgkin lymphoma (stage IV BE)

53. PETCTSCAN
•Toconfirmthe
staging.

55. IN A SUMMARY,
THE IMPRESSION OF PET CT
• Known case of Non-Hodgkin lymphoma. Current baseline
PET CT scan shows –
–FDG (F-18-deoxyglucose / Fluorodeoxyglucose) avid left
cervical, left supraclavicular, mediastinal, abdominal, pelvic,
inguinal and mesenteric lymph nodes suggests active
lymphoma.
– FDG avid bony lesion involving multiple vertebrae, sternum,
right hip bone, left femur and left 8th rib anteriorly suggests
skeletal metastasis.
–Splenomegaly with diffuse FDG uptake, possibility of splenic
infiltration could not be ruled out.

56. –Hypodense FDG avid focal mass like areas in left
kidney, possibility of neoplastic process could not be
ruled out.
–Thickened distal esophageal wall with mild FDG
uptake with luminal narrowing needs evaluation.
–Hugely distended stomach and duodenum without
wall thickening; might be due to obstruction, needs
evaluation.
–Fatty change in liver.
•Overall stage - IV

57. CONFIRMATORY DIAGNOSIS
DIFFUSED
HIGH
GRADE
NON-
HODGKIN
LYMPHOM
A (STAGE-
PEPTIC
ULCER
DISEASE
GERDẽ ẽ

58. TREATMENT
I F Y O U C A N M A K E T H E D I A G N O S I S , T H E
T R E A T M E N T I S E A S Y , A N D T H E D A M A G E C A N B E
R E V E R S E D . B U T , M A K I N G T H E D I A G N O S I S I S
T R I C K Y . – R A L F G R E E N .

59. DURING DISCHARGE – BEFORE
GETTING THE BIOPSY REPORT
• Diet- Normal
• Tab. RIMSTER (4FDC) – 4+0+0
• Tab. TIEMONIUM METHYLESULPHATE (50mg) – 1+1+1
• Tab. MECLIZINE + PYRIDOXINE HCL – 1+0+1
• Tab. AMITRYPTYLINE + CHLORDIAZEPOXIDE – 0+0+1
• Cap. FLUCLOXACILLIN (500mg) – 1+1+1+1+1
• Tab. KETOROLAC (10 mg) - 1+0+1
• Tab. ESOMEPRAZOLE (20 mg) - 1+0+1

60. OUR NEXT PLAN
• Immunohistochemistry
• Treatment according to suggestion of oncologist.

61. THANK
YOU
W I S H I N G Y O U R H A P P Y A N D H E A L T H Y L I F E