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Grand round case presentation of a 60 years old female with fever and anemia.pptx
- 1. MISSING THE TARGET-A PATIENTWITH FEVER & ANAEMIA Dr Seebat Masrur FCPS trainee Department of Medicine, SZMCH
- 2. Mrs. Rasheda Parvin, 60-yrs-old,Housewife Hailing from Upashahar, Bogura got admitted into this hospital on 19th July 2025 Known case of Hypertension, Diabetes Mellitus, CKD, Hypothyroidism
- 3. Fever for1 month. Fatigue for 1 month. A swelling behind left thigh for 6 months.
- 4. One month priorto admission into SZMCH
- 5. Fever for 1week. low grade, continued, no evening rise, without any chills & rigors, 101°F, no travelling history Fatigue for same duration Insidious, progressive, hampering her daily household chores. Swelling behind left thigh for 6 months USG and Contrast MRI of thigh - Hemangioma
- 6. INVESTIGATION(6TH JULY 2025) HB% 6.7gm/dl ESR 68 mm in 1st hr TC 22000 Neutrophil 87% MCV 78 fl/L Platelet 488000 S. Creatinine 1.9 mg/dl(eGFR 27ml/min/1.73 m2) RBS 13 mmol/L U/R/M/E Normal CXR Bilateral Pulmonary Infiltrates
- 7. After initial investigations,the patient was treated with Injectable antibiotics 3 units of blood and Supportive care. Showed partial clinical improvement and was discharged from the local clinic with a diagnosis of LRTI with Haemangioma with anaemia under evaluation.
- 8. Five days followingdischarge
- 9. Persistence of low-grade,continued fever Increasing pallor New-onset jaundice No history of pale stool, pruritus, abdominal distension, nausea, vomiting, gastrointestinal bleeding, or features suggestive of hepatic encephalopathy. Cough Dry, occasional mucoid expectoration
- 10. REPEAT LABS: (16TH JULY2025) HB% 7.6 gm/dl ESR 72 mm in 1st hr TC 26000 Neutrophil 90% MCV 79 fl/L Platelet 495000 S. Creatinine 2.0 mg/dl S. Bilirubin 10 mg/dl Liver Enzymes Not done
- 11. Referred to HepatologyDepartment of SZMCH 19/07/2025
- 12. Her complaintswere- Low grade persistent fever Jaundice Anaemia Left thigh swelling
- 13. Managed withintravenous antibiotics(Meropenem & Levofloxacin) Jaundice improved. Fever persisted. Anaemia worsened, requiring further 4-units fresh blood transfusion. Hematology consultation obtained → Hemolytic anaemia suspected → comprehensive work-up initiated.
- 14. INVESTIGATION(20TH JULY 2025) Test NameResult Hb% 6.3 g/dl ESR 85 mm in 1st hr TC 31,000 /uL Neutrophil 88% MCV 84 fL Platelet 541,000 /uL S. Creatinine 1.8 mg/dl
- 15. INVESTIGATION(20TH JULY 2025) PBF:Neutrophilic Leukocytosis, Microcytic anaemia, Thrombocytosis Reticulocytosis (3.47%) Indirect Coombs Test: Positive Direct Coombs Test: Negative
- 16. Investigation Result RBS 18mmol/L SGPT 31 U/L ALP 822 U/L Total Bilirubin 10.79 mg/dl Direct bilirubin 8.38 mg/dl Indirect Bilirubin 2.41 mg/dl LDH 211 U/L Urea 47 mg/dl
- 17. Investigation Result Stool forOBT Negative Serum Calcium 8.3(mg/dL) Sodium 126(mmol/L) Potassium 3.6(mmol/L) Ferritin (ng/mL) 4,160 (15.07.25) → 10,600 (21.07.25) Protein Electrophoresis Polyclonal hypergammaglobulinemia with marked hypoalbuminemia
- 18. At thatstage, the patient received another two units of cross- matched blood. (27/07/25) Value S. Bilirubin 1.72 mg/dl Hb% 9.6 gm/dl TC 26250 u/L
- 19. At that timemultidisciplinary medical board was conducted and decision was made to transfer her to Medicine Department of SZMCH for further evaluation.
- 20. In Medicine Department( 28th July)
- 21. Fever —for1 month Persistent anaemia — requiring repeated transfusions Swelling over left posterior thigh — gradually increasing in size for 6 months, initially painless later on became mildly painful, no trauma or discharge.
- 22. Worsening coughwith exertional breathlessness; no orthopnoea or PND. Weight loss of 5 kgs within this period of her illness.
- 23. There wasno history of syncope, palpitations, urinary symptoms, joint pain, rash, oral ulcers, photosensitivity, lymphadenopathy, altered sensorium, jaundice in the past, hematemesis, or melena. She remained compliant with medications for her comorbidities — diabetes, hypertension, CKD, and hypothyroidism.
- 24. GENERAL EXAMINATION Appearance:Anxious & ill-looking Body Build & Nutrition: Average Severely Anaemic, Not Icteric Temperature: 100.4 °F Pulse: 104/min, regular. Blood Pressure: 140/80 mmHg Respiratory Rate: 24 Breaths/min SpO : 96% on room air ₂ No clubbing, cyanosis, leukonychia, koilonychia. Lymph nodes: not palpable No edema or dehydration Thyroid not palpable No bony tenderness JVP not raised
- 25. ABDOMEN Liver palpable2 cm. No other organomegaly No palpable intraabdominal lymphadenopathy. Shifting dullness absent.
- 26. Examination of LeftLower Limb Ill-defined swelling, posterior aspect of thigh, ~6 × 5 cm, firm, mildly tender, normal overlying skin, no visible veins. Peripheral pulses were present.
- 27. Respiratory System Fewfine crepitations in both lower zones. All other systemic examinations reveals no abnormality.
- 28.
- 29. Parameter Clinic HepatologyMedicine Hemoglobin (g/dL) 7.6 9.6 6.2 WBC (×10 /L) ⁹ 26 26 34 Platelets (×10 /L) ⁹ 488 526 510 ESR (mm/1st hr) 72 45 78
- 30. Parameter Clinic HepatologyMedicine Total bilirubin (mg/dL) 10 10.8 1.72 ALP (U/L) - 822 Albumin (gm/L) - — 27 LDH (U/L) - 211 151
- 31. Parameter Clinic HepatologyMedicine S. Creatinine (mg/dl) 1.9 2.0 1.95
- 32. Parameter Result CRP (mg/L)304 mg/L Ferritin (ng/L) 10600 μg/L ANA Negative ECG Sinus tachycardia with LVH NT pro BNP 3665.50 pg/ml Bone Marrow Study Features Suggestive of Myeloid Hyperplasia
- 33. Test Result Viral &Parasitic Screen HBsAg, HCV, Kala-azar, Malaria, Leptospira ab in urine – Negative Sputum for AFB & Gene Xpert MTB/RIF Negative Blood/Urine Culture Negative Urine R/M/E Proteinuria(2+), Pus cells(8-10/HPF), RBCs (0-1)
- 34. Investigations Findings USG ofW/A Hepatomegaly, Bilateral Renal parenchymal Disease MRCP Hepatomegaly, Splenomegaly CXR P/A View Bilateral inflammatory opacities Echocardiography Concentric LVH, Mild MR, EF 65% Endoscopy Bile Reflux Colonoscopy Rectal Polyp(Polypectomy done)
- 35. Pyrexia of UnknownOrigin & left thigh Hemangioma & DM & HTN & CKD & Hypothyroidism & Anaemic heart failure
- 36. Treated withintravenous Ceftriaxone, Meropenem, Metronidazole, Levofloxacin. The patient became progressively lethargic and dyspnoeic. Decision was made to transfer her to Medicine Department of BMU.
- 37.
- 38. DIFFERENTIAL DIAGNOSIS Leptospirosis Pneumonia Hemophagocytic syndrome Septicemia Leukemia SLE
- 39. Investigation Findings Bone Scan SolidAvascular Cold Area Upper Medial Part of Thigh
- 40. In Bangladesh medicaluniversity
- 41. DIAGNOSTIC WORKUP (MIDAUG-SEP)
- 42. Parameter SZMCH BMU Hemoglobin(g/dL) 6.2 7.3 WBC (×10 /L) ⁹ 34 26.5 Platelets (×10 /L) ⁹ 510 325 ESR (mm/1st hr) 78 100
- 43. PBF 24/08/25 DimorphicRBC Mature WBC with increased total count and Neutrophil Normal platelet count Bone marrow 25/08/25 Features Suggestive of Myeloid Hyperplasia.
- 44. Test SZMCH BMU BilirubinTotal 1.72mg/dL 1.8 mg/dL Procalcitonin - 20.62 ug/L Ferritin 10600 μg/L 12784 ng/ml ALP 822 U/L 2110 U/L AST (SGOT) 92 U/L ALT (SGPT) 31 U/L 56 U/L LDH 151 U/L 307U/L CRP 304 mg/L 144 mg/L TSAT 57.93%
- 45. Test BMU PTH 23.8pg/ml Ca 5.8 mg/dl Mg 0.7 mg/dl Na 132 mmol/l K 3.8 mmol/l S. Creatinine 1.35 mg/dl Fibrinogen 759 mg/dl D-Dimer 1.35 ug/ml NT proBNP 6056 pg/ml
- 46. Test BMU ANA Negative ENAprofile PCNA+, Ku+ Sputum culture MDR Klebsiella & Candida spp. Gene Xpert Ultra MTB not detected Blood C/S(fan Method) No growth HRCT chest Bilateral pneumonitis with Right sided consolidation
- 47.
- 48. CT Abdomen& Thigh: Abscess within the thigh mass USG-guided Aspiration & Core Biopsy: Pus was sterile (no microbial growth) Sample obtained for histopathology Histopathology Report: Diagnosis: Dedifferentiated Liposarcoma
- 49. DEFINITE DIAGNOSIS Dedifferentiated liposarcoma(left thigh) with secondary soft tissue infection with Pneumonia & Anemic heart failure and HTN, DM, CKD, Hypothyroidism.
- 50. Feature Our Case (Thigh DDLPS) Vishnoiet al. (Retroperitoneal DDLPS) Presenting Symptoms Fever, fatigue, anemia, weight loss Fever, weakness, anemia, weight loss Lab Findings Anemia, ↑WBC thrombocytosis, ↑ CRP/ESR Anemia, ↑WBC thrombocytosis Diagnostic Pitfall Extensive infectious/autoimm une workup Extensive infectious workup Final Diagnosis Thigh DDLPS Retroperitoneal DDLPS Outcome Inflammation improved post- transfer Symptoms resolved after resection
- 51.
- 52. CBC Parameter 08-09-25 05-09-2531-08-25 27-08-25 15-08-25 18-07-25 Hb (g/dL) 11.2 6.2 8.7 7.3 7.50 8.1 ESR (mm/1st hr) 44 34 95 100 - 68 WBC (x10 /L) ⁹ 22.0 25.0 26.5 34.0 19.05 22.04 RBC (x10¹²/L) 4.36 2.50 3.13 2.76 3.74 3.10 Platelets (x10 /L) ⁹ 180 500 N/A N/A 477 488 Neutrophils (%) 92 92 87 90 80 82 Lymphocytes (%) 7 5 11 6 10 13 MCV (fL) 78.2 84.1 84.7 83 81 RDW-CV (%) 21.9 17.2 17.5 15.7 27.40 25
- 53.
- 54. RENAL, ELECTROLYTES RecurrentHyponatremia: Na 126– ⁺ 132 mmol/L (persistent) Hypokalemia: K 2.5–3.3 mmol/L ⁺ Hypocalcemia: Ca² 5.6 mg/dL ⁺ Hypomagnesemia: Mg² 1.0 mg/dL ⁺ Elevated Creatinine: 1.3–1.9 mg/dL → Evidence of CKD (confirmed by USG)
- 55. URINE R/M/E (05-SEP-2025) Urine R/M/E (05-Sep-2025) – Mild proteinuria (2+) with plenty of pus cells and few RBCs suggests active urinary tract inflammation, likely infective in nature (probable lower UTI). Absence of casts or crystals rules out significant tubular or glomerular involvement
- 56. BIOCHEMISTRY: LIVER FUNCTION TEST Hyperbilirubinemia:Total bilirubin peaked at 10.8 mg/dL; improved to 2–3 mg/dL Bilirubin Direct: 8.38 → 0.5 mg/dL Bilirubin Indirect: 2.41 → 1.3 Hypoalbuminemia: Low serum albumin with A/G ratio 0.65 Marked ↑ Alkaline Phosphatase (ALP): 822 U/L → 1,386 U/L (progressive rise) LDH: 211 → 151 Polyclonal Hypergammaglobulinemia: Suggestive of chronic inflammation/liver involvement
- 57. IMMUNOLOGY Inflammation & Autoimmune •CRP:very high (304 → 237 mg/L) •S Ferritin: 12784 →4264 ng/L •S. Fibrinogen: 759 mg/dl •ANA-Negative •ENA profile: RPP/PO+, Ku+, AMA-M2+ •Coombs Test: Direct positive indirect negative •SPEP: Polyclonal hypergammaglobulinemia
- 58. INFECTION Infectious disease •HBsAg negative;HCV negative •MDR Klebsiella & Candida (sputum) •Blood/urine cultures: negative •Pus aspirate thigh: no organisms, MTB negative
- 59. OTHERS ICT forKala-azar: Negative ICT for Malaria: Negative ICT for Leptospira: Negative Thyroid Function Test Normal Pro BNP 6030 pg/ml
- 60. •Bone Marrow donetwice •Hypercellular, myeloid hyperplasia, dimorphic erythropoiesis
- 61. IMAGING •USG abdomen: Hepatomegaly,CKD kidneys •Echo: Concentric LVH, mild MR, EF 65% •Chest X-ray: Bilateral inflammatory opacities •Upper GI Endoscopy: Normal •Full Colonoscopy: Rectal Polyp(Polypectomy done) •MRCP: Hepatomegaly and prominent Spleen
- 62. IMAGING… •Bone Scan: Normal.Single Solid area in thigh •USG thigh: SOL →Vascular Malformation •CT Abdomen and thigh: Hepatomegaly ,Mild Splenomegaly, Abscess in Thigh
- 63.
- 64. CBC AND PBF 29.05255.7.25 11.7.25 20.7.25 23.7.25 27.7.25 Hb 8.7 3.8 10.2 6.3 3.5 9.6 ESR 32 140 85 46% 45 TC 15350 18270 31000 32300 26250 N 91% 88% 88% 93% 95% PC 533000 372000 541000 577000 526000 PBF Normocytic normochro mic Leukocytosis
- 65. OTHER HEMATOLOGICALTEST Coomb’stest: Direct-Positive Indirect- Negative Reticulocyte count- 3.47% LDH(135-225) : 151( ) 211 (15.7.25) Ferritin-4160 (25.5.24), 10600 (11.7.25) Protein electrophoresis-Polyclonal hypergammaglobulinemia with marked hypoalbuminemia
- 66. LFT 15.7.25 24.7.25 27.7.25 Bilirubin Total10.79 2.79 1.72 Direct 8.38 1.79 Indirect 2.41 0.82 ALT 31 70 ALP 822
- 67. RFT 11.5.24 4.7.25 11.7.2522.7.25 27.7.25 Creatinine 2.1 1.5 1.80 1.59 Electrolytes Na 138 119 126 129.8 130.3 K 4.2 5.7 3.6 3.41 3.17 Cl 101 85 87 95.7 95.8 Urea 47.7 Urine RME Pus-6-10 Albumin-+ Sugar-Yellow
- 68. RBS 21.2.25 11.7.25 RBS 25.1228.7 HbA1c 9.2 S.TSH-2.91
- 69. LIPID PROFILE 21.2.25 TC 116 HDL38 LDL 52 TG 182
- 70. OTHERSTEST ANA-Negative Stoolfor OBT-Negative S. Ca++ -8.3 Vit D: 19.5 ( Insufficient)
- 71. DIFFERENTIAL DIAGNOSES Malaria (especiallyfalciparum) Fever with jaundice and splenomegaly. Secondary haemolysis common. Needs to be ruled out by peripheral smear/rapid antigen test. Mycoplasma pneumonia with hemolysis-Less likely given absence of respiratory focus but remains differential for PUO + haemolysis. Septicemia with hemolysis (e.g., Gram-negative sepsis, mycoplasma pneumonia) Prolonged fever without focus, jaundice, anaemia. Possibility of secondary haemolysis in severe infections.
- 72. DIFFERENTIAL DIAGNOSES Autoimmune HemolyticAnemia- Chronic anemia, repeated transfusions, fever, jaundice (hemolytic), pallor, mild splenomegaly Hematologic Malignancy (Leukaemia/Lymphoma)- Fever, anemia, mild hepatosplenomegaly, generalized symptoms Transfusion-Related Infection/Delayed-Hemolytic Transfusion Reaction- Multiple transfusions, chronic fever, mild jaundice, soft tissue swelling, jaundice, splenomegaly, fever, anemia Left thigh Hemangioma/Sarcoma/Hematoma/Lipoma/Abscess
- 73. Parameter 2025-09-05 2025-08-312025-08-21 2025-07-24 2025-07-16 ALT (SGPT) (U/L) - 17 - - 31 AST (SGOT) (U/L) - 27 - - - ALP (U/L) 1536 210 - - 822 Bilirubin Total (mg/dL) - 1.8 1.78 2.79 10.79 Bilirubin Direct (mg/dL) - 0.5 1.60 1.97 8.38 Bilirubin Indirect (mg/dL) - 1.3 - 0.82 2.41 LDH (U/L) - - - 151 211 Albumin (g/L) - 20 - - - CRP (mg/L) - - 144.14 - -
- 74. DIAGNOSTIC WORKUP Imaging: USGAbdomen: Hepatomegaly, CKD kidneys Echo: Concentric LVH, mild MR, EF 65% Chest X-ray: Bilateral inflammatory opacities GI Endoscopy: Normal; Colonoscopy: Rectal polyp (removed) MRCP: Hepatomegaly + prominent spleen USG Thigh: SOL → Vascular malformation Contrast MRI thigh→ Vascular malformation Bone Scan: Normal except solid thigh lesion Bone Marrow: done twice Hypercellular, myeloid hyperplasia, dimorphic erythropoiesis
- 75. As the patient’sclinical condition showed no significant improvement, she was transferred to Bangladesh Medical University for further evaluation and definitive work-up. A CT scan of the abdomen and left thigh revealed an abscess within the thigh mass, Prompting USG-guided aspiration and core biopsy. Although aspiration yielded sterile pus with no organisms on culture, the histopathological examination of the biopsy specimen demonstrated a dedifferentiated liposarcoma
- 76.
- 77. According to thestatement of the patient she was reasonably well 1 month back. Then she developed fever which is low grade, continued. Highest recorded temperature 101°F, without chills and rigors. Fever was partially relieved by antipyretics. There is no history of evening rise of temperature, drenching night sweats or contact with known TB patients. No recent travelling history to endemic zone.
- 78. Fever was associatedwith cough and breathlessness. Cough was initially dry with occasional mucoid expectoration, not blood mixed, no diurnal variation. It was not associated with chest pain.
- 79. Breathlessness was insidiouson onset, gradually progressive. Initially it was associated with moderate to severe exertion but later on it was so severe that she was unable to perform her daily activities. Patient denied any history of orthopnoea or PND, diurnal variation or relation with occupational exposure.
- 80. With these complaintsshe visited a registered physicians and after doing some routine investigations she was found anemic with raised inflammatory markers and advised for blood transfusion. 2 units of fresh crossmatched blood was transfused after admission in a private hospital. She also received IV broad spectrum antibiotics and other medications, but condition was not improved.
- 81. She developed yellowdiscoloration of her eyes, skin, urine which was progressively increasing. She did not have pale stools, itching, abdominal swelling, pain, nausea or vomiting.
- 82. For evaluation ofanemia and jaundice she consulted with hematologist and hepatologist and advised to be admitted in SZMCH. After getting treatment with IV antibiotic along with other medication her jaundice improved but anemia and fever persists. Over this period she received repeated blood transfusion.
- 83. For last 4months, she noticed a swelling behind her left thigh which was initially painless later became mild painful , progressively increasing in size with increased warmth over the area. She denied any history of trauma or discharge. Sonography was advised and reported it as Haemangioma.
- 84. During this periodof her illness she loses 6 kg body weight. There was no history of syncope, palpitation, burning micturition, joint pain, rash, oral ulcer, photosensitivity, nodular swelling in any part of the body, altered conscious level, previous history of jaundice, hematemesis or malena.
- 85. She was onregular medication for her multimorbidities like DM, HTN, CKD and Hypothyroidism with good compliance.
- 86.
- 87. On general examinationpatient is anxious, ill looking well co- operative, on choice decubitus, of average body built and nutrition. She is severely anemic, mildly icteric, temperature was 101° F, pulse 104 b/mins, BP 140/80 mmHg, respiratory rate 22 breaths/mins, spo2 96% on air.
- 88.
- 89. DEFINITE DIAGNOSIS DEDIFFERENTIATED LIPOSARCOMAOF LEFT THIGH, COMPLICATED BY SECONDARY SOFT TISSUE INFECTION & HTN & DM WITH CKD & HYPOTHYROIDISM
- 90.
- 91. PROVISIONAL DIAGNOSIS Pyrexia ofUnknown Origin (PUO) with secondary haemolytic anaemia & Diabetes mellitus & & Hypertension & Hypothyroidism & Chronic kidney disease with Left thigh solid mass Most probably: Leptospirosis Leptospirosis Prolonged fever, jaundice, renal involvement (CKD background), exposure risk through animals. Can cause haemolytic anaemia and hepatic involvement.
Editor's Notes
- #1 Bismillahir Rahmanir Rahim. Honourable Chair, respected Professors, distinguished guests, and dear colleagues — Assalamu Alaikum and a very good morning to you all. I am Dr. Seebat Masrur, FCPS trainee from the Department of Medicine, Shaheed Ziaur Rahman Medical College Hospital. It is an honour to present before this esteemed panel and distinguished audience. Today, I will be presenting a case titled “Missing the Target – A Patient with Fever and Anemia.”This case highlights how an apparently simple clinical presentation—fever and anemia—can evolve into a complex diagnostic challenge
- #2 My index patient is Mrs. Rasheda Parvin 60 yrs old muslim housewife She hails from Upashahar, Bogura, and was admitted to our hospital on 19th July 2025 for further evaluation. she has several significant chronic illnesses: such as known case of hypertension, diabetes mellitus, chronic kidney disease & hypothyroidism
- #3 The patient presented with three major complaints throughout her illnessFever for 1 month. Fatigue for 1 month. A swelling behind left thigh for 6 months.
- #4 My patient’s journey began one month before her admission to Shaheed Ziaur Rahman Medical College & Hospital, when she was first hospitalized at a local clinic.
- #5 With low-grade, continued fever for one week, with no chills, rigors, or evening rise of temperature, and no travel history. Alongside, she experienced progressive fatigue, significant enough to affect her daily household activities. Notably, she had a left posterior thigh swelling present for six months. Earlier imaging with USG and contrast MRI had identified this swelling as a hemangioma
- #6 "Initial labs revealed severe anemia, with hemoglobin at 6.7 grams per deciliter, and a raised ESR of 68 mm. Anemia was normocytic evident by MCV 78 The total leukocyte count was 22,000, with 87% neutrophils, indicating a neutrophilic leukocytosis. Platelets were elevated at 4.88 lakhs. A creatinine of 1.9 mg/dl, reflecting her CKD state at stage 4 . uncontrolled hyperglycemia. Urine examination was unremarkable CXR shows Bilateral Pulmonary Infiltrates
- #7 “Based on the initial findings, the patient was treated empirically with injectable antibiotics, received three units of blood transfusions, and was provided supportive care. She showed partial clinical improvement, mainly symptomatic, and was subsequently discharged from the local clinic with a diagnosis of lower respiratory tract infection left thigh haemangioma and anaemia under evaluation
- #8 Five days after discharge,
- #9 Mrs. Parvin was again readmitted to same clinic with persistent low-grade fever, unchanged in character, worsening pallor, and new-onset jaundice. There was no history of pale stool, pruritus, abdominal distension, nausea, vomiting, GI bleeding, or features hepatic encephalopathy. She also reported a dry, occasionally productive cough with mucoid expectoration
- #10 repeat testing, hemoglobin increased slightly to 7.6gm/dl despite 3 unit of blood transfusions. Inflammatory markers remained high — ESR 72 mm, and marked neutrophilic leukocytosis with a total count of 26,000 and 90% neutrophils. Renal function was further impaired, creatinine now 2.0. Notably, serum bilirubin rose sharply to 10 milligrams per deciliter, confirming significant jaundice.“ liver enzymes were not done.
- #11 Due to the prominent jaundice, she was formally referred to Hepatology department of shaheed ziaur Rahman medical college
- #12 Where her primary complaints included low-grade persistent fever, progressive jaundice, anemia, and a palpable left thigh swelling.
- #13 She was managed with intravenous Meropenem and oral Levofloxacin, alongside supportive care. Notably, her jaundice improved, but the fever persisted entirely unabated. Most significantly, her anemia worsened, requiring transfusion of four units of whole blood. A hematology consultation was sought, suspecting hemolytic anemia, leading to a comprehensive work-up to uncover the underlying cause
- #14 "Her latest labs showed The hemoglobin has plummeted to a critical 6.3 g/dl,. Inflammatory markers continued to rise despite treatment, ESR was 85 and total count reached 31,000, with 88% neutrophils. Platelets at 541,000. MCV 84. Renal function remained impaired, creatinine at 1.8."
- #15 The patient’s peripheral blood film showed neutrophilic leukocytosis, microcytic anemia, and significant thrombocytosis. Reticulocyte count was elevated at 3.47. Indirect Coombs test was positive, while the direct Coombs was negative.
- #16 Liver function showed a cholestatic pattern — markedly raised ALP at 822 U/L, and predominantly direct hyperbilirubinemia with total bilirubin 10.79 mg/dL. Transaminases were mildly elevated, and LDH was normal.Urea was also elevated at 47 mg/dL
- #17 Stool for occult blood was negative Electrolytes revealed hyponatremia and low-normal calcium. Ferritin levels were markedly elevated, rising from 4,160 to 10,600 ng/ml Protein electrophoresis showed polyclonal hypergammaglobulinemia with hypoalbuminemia
- #18 At this stage, two additional units of cross-matched blood were transfused. S. bilirubin fell to 1.72mg/dl, haemoglobin improved to 9.6gm/dl, and total leukocyte count remained elevated at 26,250
- #19 At that time, a multidisciplinary medical board comprising specialists from Medicine, Hematology, Hepatology, and Surgery was convened. After joint discussion, a consensus decision was made to transfer the patient to the Medicine Department of SZMCH for comprehensive evaluation
- #20 Upon transfer to our care, the clinical picture had consolidated into three persistent issues
- #21 fever for around 1 month. persistent anemia, for which she required repeated blood transfusions. And finally, a progressively enlarging swelling over the left posterior thigh over 6 months — initially painless but later became mildly painful, with no history of trauma or discharge.”
- #22 the patient also reported a cough associated with exertional breathlessness, but without orthopnoea or paroxysmal nocturnal dyspnea. There was also a significant weight loss of 5 kilograms within her period of illness
- #23 No history of syncope, palpitations, urinary or joint symptoms, rash, oral ulcers, photosensitivity, lymphadenopathy, altered sensorium, prior jaundice, hematemesis, or melena. She was Compliant with medications for her co morbidities
- #24 On general examination, the patient appeared anxious and ill. Body build & nutrition were average. Findings included severe anemia, not icteric, Temperature 100.4 f, and mild pulse rate 104 b/min. Blood pressure was stable at 140/80. Her respiratory rate and oxygen saturation were within normal limits. There was no clubbing, cyanosis, pedal edema, or lymphadenopathy. no bony tenderness, thyroid not palpable, and no dehydration, jvp not raised
- #25 The abdomen was soft and non-tender. The liver was palpable 2 cm below the right costal margin, smooth, firm, non-tender.— consistent with mild hepatomegaly. The spleen was not palpable, there was no free fluid.
- #26 On examination, the left lower limb revealed an ill-defined swelling over the posterior aspect of the thigh, measuring approximately 6 × 5 cm. The swelling was firm in consistency, mildly tender, and the overlying skin was normal, with no visible veins. peripheral pulses were palpable
- #27 On respiratory examination, fine crepitations were heard in both lower lung zones. All other systemic examinations were normal.
- #28 Now for diagnostic work-up
- #29 The haematology trend shows a progressive drop in hemoglobin from 9.6 to 6.2 g/dL despite multiple transfusions. There is persistent neutrophilic leukocytosis, thrombocytosis, and elevated ESR, with no significant change.
- #30 The total bilirubin initially elevated during the early course, later fell to 1.72 mg/dL. ALP was raised at 822 U/L, while albumin was low at 27 g/L. LDH has trended down
- #31 Serum creatinine remained stable around 1.9–2.0 mg/dL throughout admission.
- #32 The inflammatory markers are profoundly elevated. The CRP is markedly high at 304, and the ferritin is strikingly elevated above 10,000. ANA was negative. ECG showed sinus tachycardia with LVH. NT pro BNP was 3,665. Bone marrow study showed myeloid hyperplasia,
- #33 All viral and parasitic screening was negative, ruling out hepatitis B, hepatitis C, kala-azar, malaria, and leptospira. Sputum tests for tuberculosis, including Gene Xpert, were also negative. Blood and urine cultures yielded no growth. urinalysis, however, showed proteinuria, pyuria, and few rbcs.
- #34 Ultrasonography showed hepatomegaly with features of bilateral renal parenchymal disease. MRCP further showed splenomegaly. Chest X-ray revealed bilateral inflammatory opacities. Echocardiography showed concentric LVH, mild MR, and preserved EF of 65%. Endoscopy demonstrated bile reflux, and colonoscopy detected a rectal polyp, which was removed.
- #35 We dx this as Pyrexia of Unknown Origin & left thigh Hemangioma & DM & HTN & CKD & Hypothyroidism & Anaemic heart failure
- #36 The patient was initially managed with intravenous Ceftriaxone, Meropenem, Metronidazole, and Levofloxacin for presumed infectious etiology. Despite broad-spectrum coverage, she became progressively lethargic and dyspneic. it was decided to transfer her to the Department of Medicine, BMU, for further evaluation.
- #39 A bone scan was advised during the course of evaluation. However, the patient was transferred to BMU before it could be performed during her admission. She subsequently underwent the scan externally and later shared the report with us later on, which revealed a solid, avascular cold area in the upper medial part of the thigh
- #40 At Bangladesh Medical University,
- #41 an extensive Diagnostic Workup was done from (Mid Aug-early Sep)
- #42 her hematological trends showed The anemia persisted, requiring ongoing transfusional support. The leukocytosis remained significantly elevated with neutrophilia, and the ESR climbed to 100. platelets were still raised though trending down
- #43 PBF shows dimorphic RBCs, suggesting mixed anemia. Neutrophilic leukocytosis with mature cells .Normal platelets.
- #44 The biochemical profile at BMU reveals persistent mild hyperbilirubinemia and marked rise in ALP. Procalcitonin elevated. Mild transaminitis and mild LDH rise. CRP & Ferritin remains strikingly high. Tsat is elevated
- #45 Persistent hypocalcemia and hypomagnesemia with normal PTH Electrolytes: mild hyponatremia, potassium became normal. S. creatinine stable, consistent with baseline CKD. High fibrinogen and D-dimer NT proBNP markedly raised
- #46 ANA negative; ENA profile positive for PCNA and Ku antigens. Sputum culture grew MDR Klebsiella and Candida. Gene Xpert Ultra negative for MTB.. HRCT chest: Bilateral pneumonitis with right-sided consolidation
- #48 This was the turning point of the case. Initially suspected as an abscess by CT abdomen & thigh. USG-guided 150 ml pus was aspirated which was sterile Next a Core Biopsy was taken which revealed dedifferentiated liposarcoma of the thigh.
- #49 The final diagnosis was dedifferentiated liposarcoma of the left thigh, complicated by secondary soft-tissue infection, pneumonia, and anemic heart failure in a patient with multiple chronic comorbidities, including diabetes mellitus, hypertension, chronic kidney disease, and hypothyroidism. This finding not only explained the persistent systemic inflammation and non-resolving swelling but also shifted the diagnostic narrative from a presumed infectious abscess to an underlying neoplastic process, highlighting how an apparently benign febrile illness can mask a serious malignancy.
- #50 This is a strikingly similar case reported at national library of medicine— also presenting with fever, anemia, and constitutional symptoms, alongside anemia there were leukocytosis and thrombocytosis, just like our patient an extensive infectious workup dominating early focus. later DDLPS identified on CT imaging. In that case, symptoms actually resolved after tumor resection, reinforcing the malignant origin of the inflammatory picture.
- #51 Thank you for your attention and contributions
- #52 hematological profile from July to September 2025, highlighting a progressive, fluctuating anemia with initially severe hemoglobin depression (6.2 g/dL on 05-09-25), later improving to 11.2 g/dL by 08-09-25, likely following transfusion. Throughout the course, marked leukocytosis with neutrophilic predominance persisted, consistent with ongoing inflammatory or infective pathology. Thrombocytosis possibly reactive. The persistently high ESR and elevated RDW-CV reflect a chronic inflammatory and regenerative process. Overall, the evolving CBC pattern mirrors a chronic inflammatory or infectious state with intermittent hemolysis and marrow stress.
- #53 Peripheral smear shows persistent neutrophilic leukocytosis with dimorphic microcytic anemia, thrombocytosis, and compensatory reticulocytosis (3.47%).
- #54 Recurrent hyponatremia with concurrent hypokalemia, hypocalcemia, and hypomagnesemia, along with persistently elevated creatinine (1.3–1.9 mg/dL), indicates chronic kidney disease with associated electrolyte instability.
- #56 Total bilirubin peaked at 10.8 mg/dL (direct 8.38 → 0.5 mg/dL, indirect 2.41 → 1.3 mg/dL), later improving to 2–3 mg/dL. Serum albumin remained low with A/G ratio 0.65, and ALP showed a progressive rise from 822 to 1,386 U/L. Findings indicate resolving cholestatic jaundice with persistent hepatic dysfunction and inflammatory activity.
- #57 Marked inflammatory response evidenced by persistently elevated CRP, markedly raised ferritin, and high fibrinogen (759 mg/dL). Coombs Test: Direct positive indirect negative Autoimmune screening revealed negative ANA but ENA positivity, indicating a possible autoimmune-inflammatory overlap. Serum protein electrophoresis showed polyclonal hypergammaglobulinemia, consistent with a chronic systemic inflammatory process.
- #58 Infectious workup showed HBsAg and HCV negative. Sputum culture grew multidrug-resistant Klebsiella and Candida species, while blood and urine cultures remained sterile. Pus aspirate from the thigh revealed no bacterial growth and was negative for Mycobacterium tuberculosis, indicating a localized sterile inflammatory or necrotic process.
- #59 ICT for Kala-azar, Malaria, and Leptospira were all negative; thyroid function tests remained within normal limits. Excluding our provisional diagnosis
- #61 Imaging overview demonstrated hepatomegaly with CKD-related renal changes and mild splenomegaly. Echocardiography showed concentric LVH with mild MR and preserved systolic function (EF 65%). Chest X-ray revealed bilateral inflammatory opacities, while MRCP confirmed hepatosplenomegaly. GI evaluation is unremarkable except for a small rectal poly which was excised during procedure
- #62 Of particular note, the initial ultrasound of the left thigh misleadingly suggested a vascular malformation (hemangioma-like lesion), which delayed further evaluation. Subsequent CT imaging clarified the diagnosis, revealing a localized abscess within the same region, underscoring the diagnostic limitations of ultrasonography
- #63 After weeks of exhaustive evaluation, inconclusive cultures, and imaging inconsistencies, the true nature of the thigh lesion finally came to light. Histopathological examination revealed the unexpected — a dedifferentiated liposarcoma, FNCLCC grade 2, a malignant soft-tissue sarcoma often masquerading as benign or inflammatory lesions.
- #71 Malaria, especially falciparum, can present with fever, jaundice, and haemolysis Mycoplasma-related hemolysis is less likely due to no respiratory focus but can present with haemolysis Gram-negative sepsis remains a possible cause of prolonged fever with secondary haemolysis.
- #72 Autoimmune hemolytic anemia may explain recurrent anemia, jaundice, and transfusion dependency. Hematologic malignancies such as leukemia or lymphoma can mimic this presentation with fever, anemia, and organomegaly. Transfusion-related infection or delayed hemolytic reaction should be considered given her multiple transfusions. For the left thigh mass, differentials include hemangioma, soft tissue sarcoma, hematoma, or lipoma, warranting imaging and tissue evaluation.
- #75 This clinico-radiological and pathological correlation established the final diagnosis
- #77 arenheight
- #84 With these complaints she got admitted in szmch for better management
- #89 diagnosis — dedifferentiated liposarcoma of the left thigh, complicated by secondary soft-tissue infection, in a patient with multiple chronic comorbidities including diabetes mellitus, hypertension, chronic kidney disease, and hypothyroidism.This finding not only explained the persistent systemic inflammation and non-resolving swelling but also transformed the entire diagnostic narrative — from a presumed infectious abscess to an underlying neoplastic process. Despite supportive therapy and multidisciplinary management, the disease course rapidly deteriorated, culminating tragically in the patient’s demise, underscoring how an apparently benign febrile illness can conceal a fatal underlying malignancy.
- #91 So provisional diagnosis is pyrexia of unknown origin with secondary haemolytic anaemia, in a patient with multiple comorbidities — diabetes, hypertension, hypothyroidism, and chronic kidney disease — along with a left thigh solid mass. Given the combination of prolonged fever, jaundice, renal involvement, and hematologic abnormalities, leptospirosis emerges as the most probable diagnosis. This infection can produce hepatic and renal dysfunction, often accompanied by haemolysis, particularly in susceptible hosts with pre-existing systemic illness.