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A Case of Migratory Lymphadenopathy and Cutaneous Anergy in an Asian Woman

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A Case of Migratory Lymphadenopathy and Cutaneous Anergy in an Asian Woman 660 Postgrad Med J 2000;76:660–662 Postgrad Med J: first published as 10.1136/pmj.76.900.661 on 1 October 2000. Downloaded from SELF ASSESSMENT QUESTIONS A case of migratory lymphadenopathy and cutaneous anergy in an Asian woman Haider M Al Attia, Yasser H Al Ahmed, Afaf El Hag, Rima N El Abassi Answers on p 663. A 40 year old Pakistani woman presented with virus-1, herpes simplex and hepatitis B and C, one month history of fever, night sweats, and as well as serum immunoglobulins were progressive and painful swelling in the right normal or negative. Assays for antinuclear fac- side of the neck. She was febrile (temperature tors, anti-dsDNA, neutrophil cytoplasmic anti- 38–40ºC). Right deep cervical, occipital, and bodies, and rheumatoid factor were also nega- jugulodiagastric lymph nodes were palpable, tive. Computed tomography of the chest and firm, and tender. Save for a moderately severe abdomen showed normal findings. Cervical asymmetrical arthralgia of right wrist, shoulder lymph node biopsy showed an intact architec- and proximal interphalangeal joints, the rest of ture and a reactive proliferation of histiocytes, Department of her physical examination was unremarkable. transformed lymphocytes of CD8 phenotype Internal Medicine and Laboratory data showed, mild leucopenia of and plasma cells, surrounding areas of karyor- Histopathology, 3.6 × 109/l with 64% neutrophils, 26% lym- rhectic necrosis without neutrophils. There Mafraq Hospital, Abu phocytes (no atypical form), and 10% mono- were no demonstrable organisms on special Dhabi, United Arab Emirates cytes, erythrocyte sedimentation rate (ESR) 64 stains. A periadenitis was present together with H M Al Attia mm/hour, and C reactive protein of 105 mg/l a vasculities with no fibrinoid necrosis present Y H Al Ahmed (normal <10 mg/l). A skin test for tuberculin (fig 1). A diagnosis was made and she was AElHag reactivity was negative. Results of chest radio- treated accordingly. There was rapid resolution R N El Abassi graphy, blood chemistry, urine and stool analy- of fever and arthralgia within 24 hours, and the Correspondence to: sis, throat swab, blood cultures, Venereal lymphadenopathy in two weeks. Follow up at Dr Haider M Al Attia, Disease Research Laboratory test, test for HIV, three months was uneventful. Mafraq Hospital, PO Box heterophil antibodies, and serological studies After being well for two years, she presented 2951, Abu Dhabi, UAE for salmonella serotypes, brucellosis, toxo- again in June 1998 with a one month history of Submitted 9 March 1999 plasmosis, Lyme disease, Epstein-Barr virus, the same symptoms, but this time there was a Accepted 14 October 1999 cytomegalovirus, human T cell leukaemia non-tender, left supraclaviular, posterior trian- gle, and jugulodigastric lymphadenopathy. Leucopenia of 3.1 × 109/l with 7% monocytes http://pmj.bmj.com/ and ESR of 36 mm/hour were documented. All the tests that had been carried out during her previous admission were repeated. The results showed no abnormal findings. The tuberculin test was again negative. Biopsy of a left deep cervical node showed identical changes to those of the previous biopsy. She was conserva- tively managed with bed rest and administra- on September 30, 2021 by guest. Protected copyright. tion of paracetamol. The fever subsided completely after 10 days and lymphadenopathy resolved in two weeks. The patient remains well to date. During the follow up, the tuberculin test was repeatedly found to be positive. Questions (1) What was the overall diagnosis? (2) What two unusual features are described Figure 1 Area of karyorrhectic necrosis (arrow) surrounded by histiocytes (pale zone), lymphoctyes, and plasma cells (dark zone). in this case? www.postgradmedj.com Self assessment questions 661 Postgrad Med J: first published as 10.1136/pmj.76.900.661 on 1 October 2000. Downloaded from Multiple focal lesions in liver and spleen in acute leukaemia Sangeet Ghai, Sanjay Thulkar, Prakash Neduvelil Purushothaman, Sanjay Sharma Answers on p 664. An 18 year old girl presented with a two month history of fever and bleeding tendency. On examination, she had multiple petechial haemorrhages all over her body. There Figure 3 Computed tomogram shows multiple, low attenuation, rounded lesions in the spleen. One of the lesions (arrow) also shows a central nidus of high attenuation. Figure 1 Sonogram of the spleen shows multiple, rounded was no organomegaly or peripheral lympha- hypoechoic lesions, some with typical bull’s eye appearance. denopathy. Systemic examination was Institute Rotary unremarkable. Total leucocyte count was Cancer Hospital, All 117 × 109/l and platelet count 45 × 109/l. India Institute of Peripheral smear showed presence of blast Medical Sciences, New cells. Bone marrow biopsy revealed 60%–70% Delhi 110 029, India: myeloblasts. The patient was diagnosed as Department of Radio-diagnosis having myeloid leukaemia. After two cycles of S Ghai chemotherapy, the patient went into remis- http://pmj.bmj.com/ S Thulkar sion. S Sharma After three weeks, she became febrile again and developed diVuse upper abdominal ten- Department of derness and jaundice. Abdominal sonography Medical Oncology P N Purushothaman (fig 1) and computed tomography (figs 2 and 3) were performed. Total leucocyte count at Correspondence and reprint this time was 9.5 × 109/l. requests to: Dr Sanjay on September 30, 2021 by guest. Protected copyright. Sharma, A-86, Inderpuri, New Delhi 110012, India Questions (email: (1) What are the findings on ultrasound and [email protected]) Figure 2 Computed tomogram of the upper abdomen computed tomography? showing multiple small low attenuation lesions in the liver Submitted 1 June 1999 and spleen. Incidentally old calcified granulomas are also (2) What is the radiological diagnosis? Accepted 8 October 1999 seen in liver and spleen. (3) How can the diagnosis be confirmed? www.postgradmedj.com 662 Self assessment questions Postgrad Med J: first published as 10.1136/pmj.76.900.661 on 1 October 2000. Downloaded from A pregnant patient with bilateral ischaemic limbs N B Teo, N Mamode, D P Leiberman Answers on p 666. A 29 year old pregnant woman, at 35 weeks’ The electrocardiogram showed ST changes gestation, was admitted with a three day history in the septal leads with R waves in V1 sugges- of a painful left thigh and calf which was exac- tive of right ventricular hypertrophy as well as erbated by walking. She also complained of T wave inversion in the anterolateral leads paraesthesiae, muscle weakness, and coldness thought by the cardiologist to be suggestive of pulmonary thromboembolism. Chest radio- of the left foot which at times became graphy showed cardiomegaly. Full blood cyanosed. These symptoms were associated count, concentrations of urea and electrolytes, with dyspnoea on exertion. and thrombophilia screen were normal. When admitted to the obstetric ward, the left On review by the vascular team, it was noted lower limb pulses were impalpable. The left that apart from a very weak right femoral pulse, lower leg was mottled and cold but was viable. there was absence of pulses in both lower limbs, which were significantly ischaemic. After cardiological review, a transthoracic echocardiogram showed a large right ventricle with a dilated pulmonary artery. No atrial sep- tal defect was seen and there was no evidence of thrombus. Doppler ultrasound showed a 10 cm left Peripheral Vascular popliteal venous thrombus as well as occlusion Unit, Royal Infirmary of bilateral common femoral and superficial Glasgow, Glasgow, UK arteries. This was followed by a transradial NBTeo arteriogram that showed the thrombus causing N Mamode a left common iliac occlusion and a right com- D P Leiberman mon femoral arterial occlusion (fig 1). Correspondence to: Mr N B Teo, Pathology Questions Department, University of (1) What is the diagnosis? Liverpool, Duncan Building, Daulby Street, Liverpool (2) Describe the pathogenesis of this clinical L69 3GA, UK condition? (email: (3) How should the diagnosis be made? [email protected]) (4) Describe the most recent development in http://pmj.bmj.com/ Submitted 27 August 1999 Figure 1 Transradial arteriogram: left common iliac and the diagnosis of this condition? Accepted 8 October 1999 right common femoral arterial occlusions. (5) What is the treatment? Severe symptomatic hypercalcaemia on September 30, 2021 by guest. Protected copyright. José María Calvo-Romero, María del Carmen Bonilla-Gracia Answers on p 668. A 49 year old man had a six week history of and albumin 43 g/l. The blood calcium was 4.8 depression, constipation, proximal muscle mmol/l, confirmed by repeated determinations. weakness, anorexia, and weight loss of about 20 The 24 hour urinary calcium excretion was 12.3 kg. The patient was not taking any medication mmol. An electrocardiogram revealed sinus Internal Medicine and there was no history of nephrolithiasis, rhythm and shortened QT interval. Free thyrox- Service, Infanta Cristina University peptic ulcer, headache, or visual defects. Physi- ine and thyrotrophin serum concentrations were Hospital, Badajoz, cal examination showed light proximal muscle normal. Serum intact parathyroid hormone was Spain weakness without atrophy, dehydration, and no 488 µg/l (normal values 10–65 µg/l). J M Calvo-Romero other remarkable findings. The blood pressure M C Bonilla-Gracia was 140/85 mm Hg. The patient’s blood Questions chemical values were: glucose 5.2 mmol/l, urea (1) What is your diVerential diagnosis for this Correspondence to: José María Calvo-Romero, nitrogen 13.2 mmol/l, creatinine 141 µmol/l, case? Héroes de Cascorro 9, 31A, sodium 136 mmol/l, potassium 4.1 mmol/l, (2) What further investigations would you 06004 Badajoz, Spain chloride 101 mmol/l, phosphorus 1.3 mmol/l, perform? Submitted 7 July 1999 magnesium 0.98 mmol/l, alkaline phosphatase (3) What is the therapy for the severe hyper- Accepted 8 October 1999 115 U/l, creatine kinase 82 U/l, protein 76 g/l, calcaemia in this case? www.postgradmedj.com Postgrad Med J 2000;76:663–669 663 Postgrad Med J: first published as 10.1136/pmj.76.900.661 on 1 October 2000.
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