A case of 42 year old male presented with fever, weight loss and axillary swelling and shortness of breath. so what will be diagnosis and further management?
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Massive pueral effusion
1. Case Presentation
A case of 42 year old male presented with
fever, weight loss and axillary swelling
Dr. Sadia Reza Baishakhi
Indoor Medical Officer
Dept. of Medicine
EMCH
2. Particulars of the Patient
• Name : Shahid Bepari
• Age : 42 Years
• Sex : Male
• Address : Manikgonj
• Marital status : Married
• Religion : Islam
• Occupation : Driver (in Kuwait)
• Admission date : 10th November 2021
• Examination date : 10th November 2021
3. Chief Complaints
• Swelling in the left axilla for 8 months
• Weight loss for last 5 months
• Fever for 15 days
4. History of Present Illness
According to the statement of the patient he
was reasonably well 8 months back. Then he
noticed a swelling in left axilla which was
painless and gradually increasing in size. With
this complaints he went to a local hospital at
Kuwait and underwent an operation about
which he could not mention in details. He also
complaints about marked weight loss of 22kg
over the period of 5 months which is
associated with loss of appetite.
5. His bowel and bladder habit is normal and there
is no preference of hot and cold environment. He
also complained of fever for 15 days which comes
at night and associated with night sweat. Fever is
low grade (highest recorded temp – could not
mention) and subsided by taking anti-pyretics.
There is no history of bleeding from any site,
contact with TB patients. On query he also
mentioned about difficulty during breathing.
With these complaints he got admitted to EMCH
for better management.
11. General Exmination
• Appearance : Ill looking
• Body-built : below average
• Cooperation : cooperative
• Decubitus : on choice
• Anemia : mildly anemic
• Jaundice : Absent
• Cyanosis : Absent
• Edema : Absent
• Clubbing : Absent
• Thyroid : Not enlarged
• Skin : there is a incision mark (2*0.5cm)
below the left axilla
12. • Lymph node: palpable in left axillary and both inguinal
region. The lymph nodes are variable in size
and shape, largest one being 2*2cm,
nontender, firm in consistency, discrete, not
adherent to the underlying or to the overlying
structure. There is no discharging sinus.
• Blood pressure : 130/90
• Respiratory rate : 40 b/min
• Temperature : 98 F
• Pulse : 100 B/min
• SpO2 : 91% on room air
13. Gastrointestinal system
• Lip, gums, teeth, Oral Cavity and tonsils: Normal
• Tongue : pale and smooth
• Abdomen
• Inspection: no abnormality detected
• Palpation:
• Superficial palpation: no abnormality detected
• Deep palpation:
• Liver : not palpable
• Spleen: palpable, 10cm, from the left costal margin in
the anterior axillary line towards the right illiac fossa.
• Percussion : tympanic & there is no evidence of ascites
• Auscultation: bowel sound present
14. Respiratory System
• Inspection:
– Movement is restricted on left side with fullness of intercostal
space
– There is a incision mark (measuring 2*0.5cm) below left axilla
• Palpation:
– Position of Trachea: shifted to the right
– Apex beat : not palpable
– Vocal Fremitus : reduced on left side
– Chest expansibility: reduced on left side
• Percussion : Stony dull on left side
• Auscultation:
– Breath sound : Diminished on left side
– Vocal resonance : Diminished on left side
– Added Sound : Absent
15. Cardiovascular system
• Pulse: 100b/min
• Blood pressure: 130/80mmHg
• JVP : not raised
• Inspection: no abnormality detected
• Palpation:
• Apex Beat: not palpable
• Thrill: absent
• Left parasternal heave : Absent
• Palpable P2 : absent
• Auscultation: Audible 1st and 2nd heart sound and
no added sound present
16. Nervous system
• Higher psychic function: normal
• Motor function: normal
• Reflexes:
– Superficial reflexes: present
– Deep reflexes : present
• Sensory function: normal
• Signs of meningeal irritation: absent
• Cranial nerves examination: all are intact
17. Salient Feature
Shahid bepari ,normotensive , nondiabetic ,
noasthmatic, 42 years of age , hailing from
Manikgonj ,came here with the complaints of
Swelling in the left axilla for 8 months which was
painless and gradually increasing in size. With this
complaints he went to a local hospital of Kuwait
and underwent an operation about which he could
not mention in details. He also complaints about
marked weight loss of 22kg over the period of 5
months which is associated with loss of appetite.
His bowel and bladder habit is normal and there is
no preference of hot and cold environment.
18. He also complained of fever for 15 days which
comes at night and associated with night
sweat. Fever is low grade (highest recorded
temperature could not mention)and subsided
by taking anti-pyretics. There is no history of
bleeding from any site or any contact with TB
patients. On query he also mentioned about
difficulty during breathing. On general
examination, lymph node palpable in left
axillary and both inguinal region.
19. The lymph nodes are variable in size and shape, largest
one being 2*2cm, nontender, firm in consistency,
discrete, not adherent to the underlying or to the
overlying structure. There is no discharging sinus. On
GIT system examination there is presence of
splenomegaly which is 10cm, from the left costal
margin in the anterior axillary line towards the right
illiac fossa. On respiratory system examiantion, there is
restricted movement on left side of the chest, trachea
is shifted to right and there is reduced vocal fremitus
and chest expansibility on the left. Percussion note is
stony dull on left side and breath sound is also absent
on left side.
26. Blood reports
13.10.2021
S. Creatinine 81 mmol/L
SGPT 21 U/L
LDH 490U/L
Sodium 138 mmol/L
Potassium 4.2 mmol/L
S. albumin 36 g/L
RBS 5.29 mmol/L
Calcium 2.32 mmol/L
Hepatitis B Non-reactive
Hepatitis C Non-reactive
HIV Non-reactive
27. Peripheral Blood Film
date: 09.11.21
• RBC- Anisochromia with anisocytosis.
• WBC- Mature with normal count and
distribution.
• Platelet- Increased.
• Comment - Dimorphic blood picture with
thrombocytosis.
28. USG OF Whole Abdomen
Date: 06.11.2021
• Liver :Liver is mildly enlarged in size (15.7 cm) with homogeneous parenchymal echotexture.
No focal or diffuse lesion is seen. Intrahepatic biliary channels are not dilated.
• Gallbladder: Gallbladder is well outlined with normal in wall thickness No stone or biliary
sludge is seen within gallbladder
• CBD : Is not dilated. No echogenic structure is seen within lumen.
• Spleen : spleen is enlarged in size (15.4 cm in pole to pole) with heterogeneous parenchymal
echotexture. Small hypoechoic lesions are seen in the spleen.
• Pancreas:Pancreas is normal in size and echotexture. Main pancreatic duct is notdilated.
• Kidneys: Both kidneys are normal in size, shape and position. Well defined cortex
andmedulla. No stone or mass lesion is seen. Pelvicalyceal systems of both kidneys are not
dilated.
• UB: Urinary bladder is well filled and normal in contour. No intravesical lesion or calculus is
seen.
• Prostate: Appears normal in size with normal parenchymal echotexture. Capsule is intact.
• Fluid collection is seen in left pleural space (219 ml).
• Hypoechoic soft tissue mass (55 x 23 mm) is seen in upper abdomen,
• Minimal ascites is seen
29. • Comment
Splenomegaly with heterogeneous splenic
parenchyma and multiple small hypoechoic SOLs
in spleen.
D/D: i) Lymphoid neoplasm / Metastases.
ii) Infective lesion.
Left sided pleural effusion.
Upper abdominal lymphadenopathy.
Minimal ascites.
30.
31. Chest X-ray PA view
Date Comments
29.04.21 Unremarkable CXR
10.11.21 Trachea: Shifted to right
Diaphragm :Left dome and left basal angles are obscured
Heart :Shifted to right.
Lung :Opaque left hemithorax shifting mediastinum to right.
Bony thorax :Reveals no abnormality.
Comment : Opaque left hemothorax with mass effect - possibly
due to consolidation and pleural effusion on left.
32. Pleural fluid Study
date: 11.11.21
• Pleural fluid protein – 49.2 g/L
• Pleural fluid for ADA – 46 U/L
• Pleural fluid for AFB – not found
Microscopic examination (Leishman’s stain)
Total WBC count 250 cells/ cumm
Neutrophils 00%
Lymphocytes 90%
Monocytes 10%
Histiocytes 00%
RBC Plenty
33. US soft tissue
Date: 18.04.21
• Findings:
– Left axilla: multiple variable size suspicious LNs noted,
one rounded measure 1.1*1.1cm, other enlarged with
attenuated helium measure 1.8*4.3 cm and other
showing thickened cortex ~1.6cm
– Right axilla multiple LN with average size and
preserved fatty helium
– No evidence of collection seen
– No cystic or solid lesion seen
• Impressions: multiple suspicious enlarged left
axillary lymphnodes
34. US FNAC aspiration
date: 29.04.21
• Findings:
– Breast parenchyma is almost entirely fatty
– Left breast benign looking calcification focus is noted
– No mass, architectural distortion or suspicious
microcalcifications seen
– The skin, nipple and areolar complexes are normal
– Right axillla is unremarkable. Left axillary lymphnodes
are noted
• Impressions: Benign findings. BIRADS - 2
35. CT scan brain, neck, chest, abdomen
pelvis and spine
date: 10.10.21
• CT scan of the brain is within normal
• Physiological basal ganglia calcifications are noted
• Incidental small retention cysts in the right maxillary sinus and sclerotic
mastoids on the right side.
• No enlarged cervical lymph nodes.
• There is mild fullness of the left posterior and lateral wall of the
nasopharynx with no definite enhancing lesion - for clinical evaluation.
• Rest of the structures in the neck are within normal.
• The right lung as well as the aerated part of the left lung are clear.
• There is massive(left pleural effusion with collapse of the underlying
lung.
• There are significantly enlarged left axillary lymph nodes and
moderately enlarged mediastinal and hilar lymph nodes.
36. Continue
• The largest left axillary lymph node measures 4.1 X 2.1 cm, sub
carinal nodal mass measures about 4 X 2.5 cm. Right hilar node
measures about, 1.7 X 1.3 cm.
• There are small right axillary lymph nodes; no pericardial or
right-sided pleural effusion.
• There is diaphragmatic, perigastric celiac peri pancreatic, splenic
hilar, retroperitoneal (including retrocaval) lymphadenopathy.
Small mesenteric, pelvic and inguinal nodes are also noted.
• The enlarged peripancreatic lymph nodes appear to infiltrate the
pancreas resulting in illdefined pancreatic borders.
• The largest nodal mass is in the celiac region, approximately
measuring 8.5 X 5 cm (precise measurement is difficult because
the nodal mass is merging with the pancreas).
• There is splenomegaly with multiple focal defects in the spleen.
37. continue
• Smudging of the mesenteric fat is noted.
• Mildly enlarged fatty liver, no focal defects or intrahepatic
biliary dilatation.
• There is calcification in the normal-sized right adrenal. The left
adrenal cannot be clearly defined due to local
lymphadenopathy. The kidneys are within normal
• The bowel loops are essentially normal; a few uncomplicated
colonic diverticula are noted
• Normal urinary bladder and the seminal vesicles, slightly
prominent prostate.
• No ascites.
• No suspicious bone lesions
38. Bonemarrow study
date: 13.10.21
• Comment: Normocellular marrow with
trilineage hemopoiesis. No morphological
evidence of DLBCL (diffuse large B-cell
lymphoma) infiltration
39. Histopathology
date: 13.10.21
• Specimen: bone marrow core biopsy
• Microscopic description: sections show a
single core revealing with few marrow spaces
showing a normocellular marrow featuring
trilineage hematopoietic stem cells. Few
scattered (CD20 and CD79a positive) reactive
B-cells and (CD3) positive reactive T-cells are
seen. There is no evidence of lymphoma
infiltrate.
40. 18F-FDG PET/CT
date: 19.10.21
• Impressions:
• Hypermetabolic nodal (above and below the
diaphragm) , right pleural and splenic lesions
associated with hypermetabolic right pleural
effusions
41.
42.
43. Trans-thoracic echo
Date: 24.10.21
• Normal LV size for BSA. LVEF 55 % (LV EF estimated). No significant
resting regional wall motion abnormality from the available window.
Normal LV diastolic function for age. Normal LV filling pressure.
• Normal left atrium size. LA volume 44 ml (24.4 ml/m?).
• No mitral stenosis. Trivial mitral regurgitation.
• Aortic valve sclerosis. Aortic PPG is 7 mmHg. Trivial aortic valve
regurgitation.
• The right chambers are not dilated. Normal right ventricular systolic
function.
• Trivial tricuspid valve regurgitation. Pulmonary artery systolic pressure
couldn't be estimated.
• Trivial pulmonary valve regurgitation.
• Tiny pericardial effusion. No evidence of hemodynamic compromise.
Mild bilateral pleural effusions
45. Endoscopy
date: 28.10.21
• Esophagus: Normal.
• Stomach: Reticulum of fundal varices. Mild
erythematous gastritis. Biopsy was taken for
CLO test.
• Duodenum: Normal.
• CLO test came Negative
