Published on March 14, 2014
Case presentation B/L Neck swellings ID Unit - Medicine Dept. - KKUH Thursday 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 (HIV & Hep)
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.
Investigations (Chest X-ray) Report: - No focal parenchymal lung lesion -Clear CP angels - Cardiothoracic ratio within normal range
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
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