“A 51 year old male with ascites and generalized lymphadenopathy” Theo Ntenegi
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Case Report Patient: SN Sex: Male Age: 51 Address: Southern Botswana Occupation: Free-lance builder
Case History (continued) DOA: early 2018 Admitted to Male Medical Ward via outpatient clinic as a referral from hospital outpatient department.
Presenting Complaints 1. Abdominal Swelling Since late 2017, worsening since early 2018. Associated with diffuse pain. No bowel movement changes. No Hx of Melena
Presenting Complaints (continued) 2. Pedal Oedema Onset early 2018 Bilateral with no alleviating factors.
Presenting Complaints (continued) 3. Lymphadenopathy Noticed in neck area, since late 2017 More noticed in Groin area and underarms in early 2018. Gradually increasing in size and number. Painless None ruptured.
Past Medical History Weight loss noted since 2017. On and off fevers noted prior to presentation. No night sweats. No chronic cough.
Past Medical History RVD Negative (HIV negative) No Known Co-Morbidities No chronic medications No Hx. of TB treatment No Hx of STD treatment No Hx. of Hospital admission
Past Medical History Seen in health facilities several times before current presentation: • early 2018: Local Clinic – Tonsillitis and neck swelling > Given ABX. • 2018: Local Clinic - Tonsillitis • 2018: Local Clinic – Tonsillitis and neck swelling • 2018: Local Clinic – UTI, Inguinal Lymphadenopathy • Mid-2018: Local Clinic – Abdominal pain and distension > referred to hospital • Mid-2018: Hospital – Abd. Ultrasound - Hepatomegaly +Ascites > Referred to PMH.
Personal, Social and Family History Significant Drinking history >30 years. 6 – 10 units daily. Significant Smoking history +/- 10 pack years. No history of work in the mines Family history negative for malignancy.
Physical Examination Chronically ill looking, poorly nourished with abdominal distention and multiple masses on the neck region. Finger clubbing + (grade 3) No jaundice Resp: Reduced Air Entry+ Stony dull (left lower) CVS: Normal findings Abd: ++Ascites, Firm Hepatomegally (span 16) No signs of encephalopathy
Physical Examination Generalised-Bilateral lymphadenopathy, Non- matted, Size – (0.3 – 3+cm) Involving: - Cervical - Axilar - Submandibular - Antecubital - Pre + Post Auricular - Inguinal - Occipital - Popliteal - Supraclavicular
Admission diagnosis 1. Chronic live disease with portal HTN 2. Disseminated TB Vs. Lymphoma
Progress In the Ward Day 4: CXR- Left Pleural Effusion, no lesions noted. Paracentesis and Pleural Tap.
Day 9: Abd. Ultrasound – Ascites, Homogeneous Hepatomegally with no focal lesions. +Pleural Effusion. Mild homogeneous Spleenomegally. +Paraaortic Lymphadenopathy. No Pericardial Effusion.
Day 11: Ascetic Fluid : SAAG> 11g/dL, Cell Count -60; 80% Lymphocytes. No Malignant cells. Nill bacterial growth. Pleural Fluid: Exudative.
Pathology LN Biopsy done (cervical) – Reported on day 31 – LN with fibrotic thickened capsule and total architectural effacement. Tumour with mixed reactive component including plasma, lymphocytes, plasma cells, neutrophils and histocytes. – Features favouring Hodgkin Lymphoma – Nodular Sclerosing Type. – Histologically and immunohistochemically consistent with Hodgkin Lymphoma.
Pathology
Pathology
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Pathology
Day 24: OGD- Early lower eosophageal varices. Day 32: Oncology review. Requested CT Head, chest, abdo, pelvic. To be initiated on chemo and refered to chemo clinic.
Day 35: Developed Confusion – encephalopathy (GCS 14/15) Became Septic (febrile, confused, tachypnoec) Transferred to High dependency cubicle and septic workup initiated. Started on Meropenem. Oncology r/v requested.
Day 38: Oncology Review Septic, GCS 11/15, Left Pleural Effusion. Not for any Oncological treatment. Oncology request review once medically fit – suggested palliative care. Day 45: Death Notification
Chest X-ray: on admission
Chest x-ray: during admission
A 51 year Male, RVD Negative (HIV negative) Presenting with Generalised Lymphadenopathy, ascites and hepatomegally. Final Diagnosis: Advanced Nodular Sclerosing Hodgkin Lymphoma. Stage III2 (Modified Ann Arbor – Cotswold)
Investigations Reference 20/08/2018 23/08/2018 30/08/2018 03/09/2018 10/09/2018 Ranges WCC 4-10 9.44 8.55 8.3 8.2 HB 12-15 10.6 11.1 12.8 12.3 MCV 83-99 93.8 92.9 94.6 94.5 PLTS 150-400 264 270 325 224 Neut 2-7.0 5.0 5.1 5.1 5.6 Lymph 1.0-3.0 1.5 1.1 1.1 1.0 Eosino 0.02-0.5 0.2 0.0 0.18 Na+ 135-145 130 126 132 125 K+ 3.5-5.1 4.16 3.96 4.4 6.6 Urea 2.0-7.0 2.5 3.2 4.1 4.08 Creat 53-97 36 34 35 32 Ca 2.2-2.6 2.01 Mg 0.6-1.10 0.69 Phos 0.8-1.55 1.12 Tot Prot 60-80 61.2 78.4 55.2 59 58.2 Tot Bil 1.0-25.7 11.6 7.68 13.6 Conj Bil 0-3.0 Albuim 35-55 23.9 22.7 25.7 21.8 ALP 35-110 183 153 170 205 GGT 11-50 172 169 193 240 229 ALT 11-40 9.1 7.8 6.0 5.3 10 AST 10-34 32.8 26.8 27 34 34 LDH 210-425 205 211 INR 1.21 1.4 APTT 25-45 29.6 32.8 33
Hasenclever Score Hasenclever Score Score 0 1 Patient’s Score Serum albumin Normal <40 g/L 1 Haemoglobin >10.5 g/dL <10.5 g/dL 0 Age <45 >45 1 Sex Female Male 1 Stage <IV IV 0 Leucocytosis <15x10 9/L >15x10 9 /L 0 Lymphopenia >0.6x10 9 /L <0.6x10 9 /L 0 Cumulative Score 3
Discussion Approach to a patient with suspected Hodgkin Lymphoma. Criteria for Chemotherapy fitness. Staging Hodgkin Lymphoma. Preparation and Investigations prior to Oncology referral.
Questions What can be done to promote early diagnosis of treatable malignancy in Botswana. Are there any investigations that can be done in peripheral health facilities to support early Diagnosis of Malignancy. What strategies can we put in place to train new doctors on how to send samples for investigation to the National Health Lab. Available investigations in PMH.
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