Fever and lymphadenopathy approach.

1. Fever and
lymphadenopathy
Presenter: Dr Junaid Yousuf
PG resident General medicine
Consultant Incharge: Dr Afaq (Asst. Prof. clinical hematology)
SR Incharge : Dr Satya Prasad Namala

2. Patient Profile
• 60y/F
• Married having 5 kids
• Resident of Poonch, J&K
• Housewife

3. Chief complains
• Fever -4weeks
• Swelling over neck-3 weeks.

4. History of present illness: FEVER
• Duration-4 weeks
• Documented with max spike of 103F.
• Intermittent
• Predominantly evening rise
• With short term relief by antipyretics
• Also received IV antibiotics (Ceftriaxone 1 gm IV BD for 1 week), with no
response.

5. History of present illness
• Associated with chills, increased sweating.
• Abdominal pain, located left upper abdomen.
• Dragging in nature, mild intensity, with short term relief by analgesics.
• Significant weight loss of 10 kgs in 2 months.
• Loss of appetite.
• Easy fatiguability and generalized weakness.

6. No history of
• Cough, dysnoea.
• Chest pain.
• Loose stools.
• Jaundice.
• Dysuria, frequency, hematuria, urethral discharge.

7. No history of
• Headache, photophobia, abnormal movements.
• Rash
• Contact with animals
• Recent travel to outside
• High risk behavior
• Morning stiffness
• Joint pains
• Dry eyes
• Bony pains

8. History of present illness contd..
NECK SWELLING
• Duration 3 weeks.
• Located in the left side of neck.
• Noticed by patient herself.
• Small swelling ,with no associated pain or any discharge.
• Progressive increase in swelling over this time.

9. Past illness
• Patient is a known case of T2DM for 3 years on oral diabetic drugs, uncomplicated
as per records.
• No history of similar illness in the past.
• No history of HTN, thyroid disorders, old treated malignancy, old treated
tuberculosis.

10. Personal history
• Post menopausal.
• Having 5 kids.
• Mixed diet.
• Normal bowel/bladder.
• Decreased sleep and appetite.

11. Family history
• History of hypertension and T2DM in mother.
• No history of malignancy in family.
• No h/o ATT intake in family.

12. Drug history
• Metformin 500+Glimepride2mg from 3 years.
• Received I.V antibiotics for 1 week (Ceftriaxone 1 gm BD) prior to our admission.

13. SUMMARY
• 60/F underlying T2DM with a 4 week history of fever and neck swelling with
associated h/o constitutional symptoms in the form of generalized weakness, mild
left upper abdominal discomfort and weight loss.

14. Differentials
Infections
Viral
(EBV/CMV/HIV)/
Viral Hepatitis
EBV
CMV
HIV
No URTI, Duration,
No Myalgias
Fever and
Lymphadenopathy
Fever and
Lymphadenopathy
No High risk
behavior
Fever and
Lymphadenopathy,
Weight Loss
No URTI
Viral Hepatitis
Fever and abdominal
pain Lymphadenopathy

15. Differentials
Infections
Bacterial
• TB
• Brucella
• CAT scratch
• Atypical MTB
TB
Brucella
CAT
Duration, No contacts,
No RT symptoms
Fever, Weight loss and
Lymphadenopathy
Fever and
Lymphadenopathy
No rash/scratch
Fever and
Lymphadenopathy,
No animal contact
Atypical
Mycobacteria
Fever and
Lymphadenopathy,
No RT Symptoms/
No IS

16. Differentials
Infections
Parasitic
• Toxoplasma
Fever and
Lymphadenopathy
Duration of fever, No
Immuno suppressed
state

17. Differentials
Malignancies
• Lymphomas
• Leukemias
• Solid Organ
Lymphoma
Leukemia
Age, Fever,
Lymphadenopathy & B
Symptoms
Age, Fever,
Lymphadenopathy
No bony pains,
bleeding
Solid organ
Malignancies
Lymphadenopathy,
Weight loss
Fever

18. Differentials
CTD
SLE
Sjogrens
Scleroderma
MCTD
SLE
MCTD
Sjogrens
No rash, arthralgias or
ulcers
Age, Fever, Weight loss
and Lymphadenopathy
Age, Fever, Weight loss
and Lymphadenopathy
No SICCA
Age, Fever, Weight loss
and Lymphadenopathy
No rash, arthralgias
or ulcers
Scleroderma
Age, Fever, Weight loss
and Lymphadenopathy
No Dermatology

19. Differentials
Others
Lymphoma mimics
• Kikuchi
• Castlemans
• Rosai Dorfmans
• Sarcoidosis
Kikuchi
Castleman’s
RD
Age, Fever, Weight loss
and Lymphadenopathy
Age, Fever, Weight loss
and Lymphadenopathy
Duration, large
nodes, relapses and
remissions
Age, Fever, Weight loss
and Lymphadenopathy
Duration, large
nodes, relapses and
remissions
Sarcoidosis
Age, Fever, Weight loss
and Lymphadenopathy
No RT symptoms

20. Examination
• Patient is conscious cooperative oriented to time, place and person.
• Pulse: 92 regular synchronous with the other side, and other pulses normal.
• Bp :110/70 mmhg
• Sp02 : 94% RA
• RR: 18/min

21. General Examination
• Pallor: Present
• Icterus: Present
• Cyanosis: absent
• Pedal edema present
• JVP not raised

22. Neck
• Cervical lymphadenopathy present
• 2 x 1.5 cm node present in left posterior triangle level 5
• Firm in consistency.
• Mobile
• Non tender
• Overlying skin normal
• Multiple other nodes less than one cm in b/l neck level 2 & 3.
• Thyroid: No goitre.

23. Oral Cavity
• Tongue moist.
• Normal faucial pillars.
• Post pharyngeal wall normal.
• No tonsillar hypertrophy.
Normal breast examination.

24. Axilla/Inguinal
• Axilla : Multiple nodes largest around 2cm freely movable present in left axilla
non tender
• Inguinal region- no inguinal LAP
• Nails no clubbing, discoloration of nails.

25. Chest examination
• Inspection: Normal shape, no deformity, no scar or dilated veins, symmetrical rise
of chest
• Palpation: No tenderness, symmetrical chest movements. Chest expansion 6 cm.
• Percussion: normal resonant note heard all over lung fields except area of cardiac
dullness.
• Auscultation: Normal vesicular breath sounds. No crepts/wheeze.

26. CVS
• Inspection: No deformity, apex not visualized.
• Palpation: Cardiac apex felt in 5th i/c space.
• Percussion: Area of cardiac dullness in 4th to 6th i/c space.
• Auscultation.S1S2 heard in all areas of auscultation ,no added sounds or murmurs.

27. Central nervous system
• HMF: normal
• Sensory system: normal
• Motor system: Normal
• Reflexes: Present
• Cerebellar Signs: absent

28. Abdominal examination
• Normal contour, umbilicus inverted no visible colour change or dilated
veins/scars.
• Mild hepatomegaly, liver palpated 3 cm below costal margin, with normal
consistency of inferior border. Liver span 17 cm.
• Moderate splenomegaly, spleen palpated 5 cm below coastal margin
midway between coastal margin and umbilicus.
• No other palpable organ/mass.
• No fluid thrill, no shifting dullness.

29. Summary
• 60 year female with B symptoms and lymphadenopathy and
hepatosplenomegaly.
• Possibilities : ??

30. Differential diagnosis on history and
examination
• Malignancies Likely, hematological (Lymphoma, Leukemias).
• Infections : Tuberculosis.
• Auto Immune.
• Viral hepatitis.
• Others atypical lymphoproliferative disorders.
• Solid organ Malignancies.

31. Investigations:
• Hb: 7.1, TC: 5.6, PLT: 24, Normal: N/L/M: 65/20/13. MCV: 92, ESR: 72.
• PBF: Normocytic anemia, severe thrombocytopenia, no abnormal cells.
• Urea, Creat: 40/1.2
• Calcium: 8.0
• Phosphorous: 3.84.
• LDH: 960. CPK: 46, UA: 5.96.
• Retic: 2.5.
• BIL: 8.4 (I/D): 4.4/4.0.
• ALT: 26, ALP: 455, TP: 5.8, ALB: 2.45.
• PT: 15, INR: 1.1, APTT: 29.

32. Investigations:
• pH:7.40, Hco3:19, Na: 148, K: 3.66, pCo2:32.
• RUE: 2-4 pus cells, no protein, no rbcs.
• ECG: Sinus rhythm.
• Xray Chest: Normal, no mediastinal widening, no effusions.

33. Investigations:
• Bone marrow aspiration. Hypercellular marrow with normal cell lines, no
infiltration in aspirate smears, no blasts, no atypical cells.
• Bone marrow biopsy: awaited, have to rule out infiltration in view of unexplained
cytopenias.

34. Investigations:
• Blood/urine culture: Sterile
• Sputum g/s; culture: negative
• Sputum for AFB : no AFB seen
• Mantoux: Negative.
• ICT/DCT: Negative.

35. Radiological investigations : USG
• Spleen is 16 cm, enlarged in size. Hypoechoic lesions in b/l adrenal
glands.
• Multiple enlarged lymph nodes seen in peripancreatic, periportal,
paraaortic locations with maximum of 26 mm.
• Liver is enlarged in size with few hypoechoic lesions seen in both
lobes largest one 38*33,IHBRD and CBD not dilated
• Segmental area of circumferential thickening in small bowel in left
iliac fossa.

36. CECT abdomen & Pelvis
• Bilobar hypovascular hepatic leisions.
• Areas of segmental circumferential mural thickening of small
bowel(jejenum/ileum).
• Multiple enlarged occasionally conglomerating, periportal peripancreatic,
paracaval and mesenteric lymph nodes.
• Bilateral adrenal masses with small hypodense non enhancing area.

39. HPE
Cervical LN excision bx
• Sheets of round to oval cells with
hyperchromatic nuclei and mild amount of
cytoplasm suggestive of poorly
differentiated carcinoma/non Hodgkin
lymphoma
IHC
Positive makers-LCA/CD20/ki67/CD79a/PAX5
Negative markers:
SOX11/BCL6/CD10/CD23/CD30
High grade b cell lymphoma
DIFFUSE LARGE B CELL LYMPHOMA
Diffuse large B cell lymphoma. The majority of
cases contain a mixture of large cells that
resemble centroblasts with peripheral nucleoli
and a minority of large cells that resemble
immunoblasts with central nucleoli.

40. Final diagnosis
Diffuse large B cell
lymphoma
Stage III

41. Management
• Patient was started on R-CVP protocol after confirming of diagnosis
and received 1st cycle uneventfully.
• After starting the chemotherapy her, bilirubin has plumped down to
normal.
• Lymphadenopathy reduced in volume.
• Her GC has improved, now asymptomatic.
• She is being discharged today.