This 33-year-old male soldier with HIV presented with 4 months of fever, neck swelling, and weight loss. He has a history of immunosurveillance, tuberculosis lymphadenitis, and genital herpes. Examination found cervical lymphadenopathy. Tests showed pancytopenia and Hodgkin's lymphoma in cervical lymph nodes. He was started on ART and chemotherapy but developed recurrent infections including herpes and cellulitis, delaying further chemotherapy.

1. SATURDAY CLINICAL MEET
INTERNAL MEDICINE
UNIT 4
1

2. Personal particulars
• 33 yrs/M
• Serving soldier
• Master in Computer Application (MCA)
• Resident of Delhi
• Informant Self
• Reliability good
2

3. • Immunesurviellence
– Onset – 2008
• Detected during evaluation of genital Herpes
– CD4 Profile :-
– Viral Load – 11152 copies/ul
3
Year CD4 Year CD4
Initial : 2008 287 cells/ul Aug 2014 313 cells/ul
Feb 2012 147 cells/ul May 2015 90 cells/ul
Aug 2012 345 cells/ul Aug 2016 40 cells/ul
Nov 2012 323 cells/ul Jan 2017 64 cells / ul

4. History of Present illness
• OIs
- Genitial Herpes
- Tubercular Lymphadenitis (Apr 2012)
Completed 9 months ATT
- Tenia Cruris
• Spouse – Retropositive on ART
• Children - Nil
4

5. – ART : ZLN (Apr 2012 with HRZE)
↓
TLE (DILI May 2012)
↓
Zidovudine + Lamivudine + Darunavir + Ritonavir +
Raltegravir (Sep 2016) due to viral and
immunological faliue
5

6. Presenting complaints
• Fever with chills x 4 Months
• Bilateral neck swelling x 4 months
6

7. History of Present illness
• Fever – Low to Moderate grade
Associated with chills, No rigors
• Constitutional symptoms
• Night Sweats
• WEIGHT LOSS -
Not associated with cough, pain abdomen,
dysuria, vomiting, rash.

8. History of Present illness
• Weight Loss – 12 Kg in 04 months
• unintentional
• Reduced appetite
• Swelling in the neck Lt  Rt
• Increasing in size over 3 weeks
• No h/o protrusion of eye, palpitation
• diarrhea, hyperhidrosis, intolerance to heat
• No h/o bone pain/ bleeding gums.
Swelling axillae/groin, abdominal fullness.

9. • No h/o vomiting/nausea/pain abdomen/loose
stools
• Dysuria/oliguria/haematuria
• Skin rash/joint pain or swelling
• Cough/dyspnea/hemoptysis/chest pain
• Altered sensorium/headache/neckstiffness

10. Other Disabilities
• B/L SNHL (Onset 2005)
- Cause occupational noise exposure

11. Past history
• No history of DM/HTN/Br Asthma/Jaundice in
the past.
• No significant past surgical history

12. Personal history
• Mixed Diet
• No history of any addiction.
• Bowel & bladder normal
• Sleep
12

13. Family history
• Spouse – Seropositive on ART
• No h/o similar illness in the family.
13

14. Summary

15. Summary
• 33 years old male, a case of
immunesurveillance with OIs of TB
Lymphadenitis and Genital Herpes ,on third
line ART presented with complaints of Fever,
Neck swelling and B symptoms of 4 months
duration
15

16. Gen examination
• Ht :168cm ,weight:56kg, BMI-19.84 Kg/m22
• P: 92/min, regular, normal volume and
character.
• BP: 126/80 mm Hg
• RR: 16/Min
• SPO2: 96% on
• Tenia Cruris, Genital Herpes
16

17. Gen examination contd.
• Pallor +
• B/L cervical LNE – 1.5 x 2 cm level IV & V firm,
matted, non tender, mobile
• Rt Axillary LNE : Medial Gp 1 x1 cm mobile.
• Rt Inguinal LN : 1.5 x 1 cm mobile
• No icterus, clubbing, cyanosis, oedema
17

18. Systemic examination
• P/A: Soft, non tender
– Spleen palapable 1 cm below LCM,
– Margins smooth
– Non tender
– Liver palpable 2 cm below RCM
– Non tender
– Margins smooth
– Span 15 cm
• Respiratory examination :
B/L air entry equal
18

19. Systemic examination
•CVS
– S1 and S2 Normal
– No S3, S4
– No murmurs
•CNS
- No focal Neurological deficit
19

20. Investigations
Parameter Patient Value Parameter Patient Value
Hb(gm/dl) 8.7 Urea/Creat(mg/dl) 13/0.65
TLC (cells /mm3)
16800 Na/K/Ca/Po4 (mEq/L) 132/4.20/7.50/4.20
DLC P65/L25 Bil(Tot/Dir) (mg/dl) 0.15/0.10
PLATELETS 3.7L TProt/Alb/Glob(g/dl) 7.20/3.0
ANC 10820 AST/ALT/ALP/LDH 22/32/88/331
PT/APPT/INR 12.6/29/1.07 Uric Acid 5.6
Urine C/S No growth CRP positive
URINE REME NAD HBsAg/Anti HCV Negative
Urine for Bile salt Negative DLCO/PFT Normal Study
B Sugar F/PP 80/101 S iron study/ TIBC Iron: 84, TIBC: 380
Dengue serology Negative CXR WNL
TORCH Negative ECG WNL
04/02/17
DEPARTMENT OF INTERNAL
MEDICINE
20

21. Investigation
• X Ray Chest :- NAD
• USG Abdomen (20/09/16) – Hepatosplenomegaly;
Retroperitoneal Lymphadenopathyl
• USG Neck (22/08/16) - B/L cervical Lymphadenopathy
• Bone Marrow Biopsy: Cellular reactive bone marrow. No
granulomas or lymphoma deposit seen
• Bone marrow Aspirate: Cellular bone marrow.
• ECG – WNL

22. Investigation
• USG Guided LN FNAC
– Rt Cervical LN.
– Zn stain negative
– Few scattered atypical cells with high NC ratio,
coarse chromatin and prominent large nucleoli –
Granulomatous Lymphadnitis
– Impression: Likely TB, adv excision biopsy
• Gene Xpert: MTB not detected,.

23. Investigation
• Excision Biopsy :
– Classical Hodgkin Lymphoma
– RS Cells with occasional binucluate and also
mono nuclear forms in a backgound of
lymphocyte / esoinophil
– CD30 positive, CD45 – Negative, CD15- Negative,
Pax- weakly positive, CD20- Negative, CD3-
Negative.

24. Investigation
• PET Scan : Metabolically active multiple
lymph nodes involving cervical axillary
supraclavicular, abdominal and pelvis
locations with mildly increased metabolic
activity of spleen
• Ann Arbor stage III B

25. Management
• Declining CD4 count + viral load 11,152.
↓
Salvage regimen ART
Zidovudine+Darunavir + Ritonavir+ Raltegravir +
Lamivudine

26. Management
• Chemotherapy initiated with monitoring for
TLS
• 2 D ECHO, PFT and DLCO – NAD
↓
ABVD 1st
Cycle 4/10/16

27. Management
• Complications
– Mucositis
– Exacerbation of Tenia Cruris
– neutropenia (ANC-138)
- Managed with Neutropenia Precautions
- Inj GCSF
- Antibiotics
- Continue to be afebrile + counts improved

28. Management
• 2nd
cycle of Chemotherapy (3/11/16)
↓
- 1 episode of fever + vomiting
- + Febrile Neutropenia
- managed with antibiotics, GCSF and transfusion of Blood
component. (Blood culture negative)

29. Management
• 3nd
cycle of completed on 19/12/16
↓
– Recurrent infection on the form of Herpes
Genitals and multiple folliculitis
• Pus culture : Coagulase – Negative Staph
– MRSA sensitive to vancomycin
– NASAL Swab for MRSA : No growth
• Perianal Abscess
- Fissure in ANO

30. Present Status
• Present status : Awaiting resolution of
Perianal abscess  4th
cycle of C.T

31. Aim of presentation
• An approach to a case of lymphadenopathy
• An approach to a case of HIV-lymphoma

32. Thank you