This quiz is for all you young doctors let’s see if anyone of you can solve
this one:
38 years old female presented with complaint of fever off and on since 6 months along with pain in right hypochondrium.She also had weakness and lethargy along with fever.She visited a number of general physicians and was prescribed antibiotics off and on but her fever did not subside.Her family and personal history was unremarkable.On general examination, there was no palpable lymph nodes and rest of the examination was unremarkable.Systemic examination revealed tenderness in right hypochondrium but there was no hepatosplenomegaly.Her complete blood counts showed leucopenia.Hence bone marrow and trephine was performed.Ultrasound abdomen showed multiple enlarged lymph nodes in retroperitoneum mesentery and around porta hepatic but these lymph nodes were not accessible for a biopsy.Bone trephine(H & E) section showed multiple caseating granulomas
What may be the underlying problem?Think about it and let me know
Tuberculosis. the combo of fever, lethargy occuring already for 6 months.... together with enlarged lymph nodes, leucopenia and caseating granulomas makes TBC the most likely cause.
other things include:
-some rare bacterial or protozoal infection
-sarcoidosis
-leukemia or lymphoma
If sarcoid is on the list and a biopsy is not possible, I would recommend a chest X-ray. Sometimes this disease will present with a spot on the lungs that shows up on X-ray.
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*Originally posted by X_Communist: *
Why did she mention hepato-spleenomegalY?
rt. hypochondrium is liver...where'd the spleen come in? does the spleen expand so far to the right in spleenomegalY?
im tryin to catch up here, can you people explain the terminology as you make ur guesses - so i can try n understand better? THanks.
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hepatosplenomegaly -
no, usually don't expect the spleen to become so large that it would come to the right side and when the spleen becomes large, it usually expands downward towards the left lower quadrant and towards the umbilicus.
its always important to know if such a patient has an enlarged liver or spleen, your differential diagnosis may change if there is hepatosplenomegaly.
[QUOTE] Originally posted by Ghazala Nasir: *
Systemic examination revealed tenderness in right hypochondrium **but there was no hepatosplenomegaly.
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X-comm - here's a brief description of sarcoidosis.
"Sarcoidosis is a disease that causes inflammation of the body's tissues. Inflammation is a basic response of the body to injury and usually causes reddened skin, warmth, swelling, and pain. Inflammation from sarcoidosis is different. In sarcoidosis, the inflammation produces small lumps (also called nodules or granulomas) in the tissues."
Hi guys,
Thank you all for participating.The answer to the quiz is:
A granuloma is composed of macrophages, epitheloid cells, lymphocytes, plasma cells, multinucleated giant cells and fibroblasts.Coalescence of macrophages gives rise to multinucleated giant cells (langerhans’s cells).They are not unusual in bone marow and may be found in hypocellular, normocellular or hypercellular marrow.
Granuloma formation occurs in response to numerous agents including mycobacterium, fungi, toxoplasmosis, hitoplasma, malignant lymphoma, Hodgkin’s disease, sarcoidosis, primari biliary cirrhosis, Q fever, infectios mononucleosis.
It is not unusual to find granulomas in bone trephine biopsies and one can always think of performing a bone trephine biopsy if lymph nodes are not assessable for a tissue diagnosis of tuberculosis.
