Case presentationB/L Neck swellings

ID Unit - Medicine Dept. - KKUHThursday 23rd January 2014

Khalaf Alghamdi, MBBS

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

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

Contd..

• Seen by doctor in private care center in Philipin

• Augmentin only was prescribed for her• Taken for one month• No relieve

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

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

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

Contd..

• She is single• Living with her family in a rented apartment in

Riyadh• Average economic status

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

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

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

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

Investigations (CBC & ESR)

Investigations (U&E)

Investigations (HIV & Hep)

Investigations (Preg)

Investigations (VDRL)

Investigations (MSU)

Investigations (True cut AFB)

Biopsy Official Report:Site of specimen: Lt. cervical lymph nodeType: True cut biopsyShowed 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.

Investigations (Chest X-ray)

Report:- No focal parenchymal lung lesion-Clear CP angels- Cardiothoracic ratio within normal range

Investigations (US)

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

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

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