Case Presentation Infectious Diseases

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Case Presentation Infectious Diseases

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  • 1. Case presentation B/L Neck swellings ID Unit - Medicine Dept. - KKUH Thursday 23rd January 2014 Khalaf Alghamdi, MBBS

2. History N. A. Cairoden 21 YO Filipino, female Student in PNU Not known to have any chronic medical illnesses Presented to the clinic in 27th Nov. 2013 with 1 year Hx of left neck swellings History taken from the patient through translator 3. History of PC Norain was in her usual health state till 1 year back when she, incidentally, noted a swelling in the Lt. side of her neck, when she was in Philipin Initially, it was only one, small in size, painless, then another swelling developed below the old one within few days. They got increased gradually in size (like a big olive) and still constant Some times can be felt warm, and occasionally painful 4. Contd.. Seen by doctor in private care center in Philipin Augmentin only was prescribed for her Taken for one month No relieve 5. Contd.. There was NO hx of Fever Cough SOB Difficulty in swallowing Night sweat Rash General malaise Weight loss Joint pain Dental infection URTIs Nausea or vomiting 6. Contd.. No hx of previous same complaint ,, ,, of same illness in her family members ,, ,, of contact with animals ,, ,, of sexual relationships ,, ,, of using herbal medications ,, ,, of travelling before onset of complaint 7. Contd.. No past hx of hospital admissions No past hx of surgical operations No past hx of blood transfusion She is not known to has any allergy for drugs, foods or chemicals BCG and HepB virus vaccines taken at childhood 8. Contd.. She is single Living with her family in a rented apartment in Riyadh Average economic status 9. Physical Ex. She was looking well, fit Oriented to T, P, P VS: BP=130/80 HR= 80 Temp=36.6 O2 Sat=97% on RA Pain score=0 Tall= 155 cm Weight= 50 kg 10. Physical Ex. Neck ex.: There were two visible & palpable masses on the left side of her neck beside each other, one is submental (1x2 cm) and the other is lower and smaller There is palpable mass on the right side of the neck less than 1X2 cm They were firm, mobile, not fluctuating, not tender, no sinus or discharge, skin is intact and normal in color No other swellings in the neck Lymphatic system: no enlarged tonsiles, posterior cervical, occipital, axillary or inguinal lymph nodes 11. Physical Ex. There was no clubbing No signs of dehydration, normal skin color Chest: normal and equal breath sounds with no added sounds CVS: normal heart sounds, no added sounds Abdomen: soft and lax. No tenderness. No organomegaly 12. Investigations She was seen previously by occupational health care and referred to ID clinic Labs requested: CBC with ESR, U&E, HIV, Hep, Preg, VDRL, blood group, MSU, True cut specimen for AFB and biopsy Chest X-Ray Ultrasound 13. Investigations (CBC & ESR) 14. Investigations (U&E) 15. Investigations (HIV & Hep) 16. Investigations (Preg) 17. Investigations (VDRL) 18. Investigations (MSU) 19. Investigations (True cut AFB) Biopsy Official Report: Site of specimen: Lt. cervical lymph node Type: True cut biopsy Showed Necrotizing granulomatous lymphadenitis. Comment: special stain for AFB and GMS are negative. Although the AFB is negative, the histopathological picture is highly suspicious for tuberculosis. Clinicopathological correlation is recommended. 20. Investigations (Chest X-ray) Report: - No focal parenchymal lung lesion -Clear CP angels - Cardiothoracic ratio within normal range 21. Investigations (US) 22. Investigations (US) US Official Report: Findings: There are multiple bilateral enlarged hypoechoic cervical lymph nodes. The largest lymph node on the right side measures 0.7 x 0.9 cm and the largest lymph node on the left side measures 1.8 x 1.0 cm. Conclusion: -bilateral cervical lymphadenopathy -FNA correlation is suggested 23. Admission She was admitted electively under ID team (after seen in OPD) on Sunday 19th Jan. 2014 for excisional biopsy CBC: WBC = 5.4 HGB = 12 PLT = 307 ESR = 51 MSU = absolutely normal U & E = absolutely normal Coagulation profile = absolutely normal 24. Treatment On Tuesday 22nd Jan. 2014 Excisional biopsy done under GA for the left enlarged lymph nodes only Patient has been started on oral ATT as a guideline of pulmonary TB treatment Patient discharged Appointment x2/52 for ID OPD for follow up and LFT & ESR