Case 5.7

Case Presentation by Dr. Tim Scott

CC: Fatigue

HPI:  19yo W M with no PMH presents to the ED with complaint of fatigue.  He states that over approximately the last 6 months he has noticed that he has decreased energy that has gotten progressively worse.  He is single, lives with a room-mate and is employed.  He has no history or family history of depression.  He denies drug/alcohol abuse.  He denies any hematuria, dark or bloody stools and any other complaints.

ROS:  Positive for fatigue

PMH: Denies

PSH: Denies

Social: Denies smoking or drug use.  Drinks occasionally with friends

PE:  Pulse 86, Respirations 16, Temp 37.1, PaSO2  97% RA

Const: W/D, W/N Appears stated age, NAD

HEENT:  membranes moist, left side painless cervical lymphadenopathy, trachea midline

CV: RRR, S1 S2

Lungs: CTAB

Abd: Soft, NT/ND, BS +

Extr: normal pulses, strength and ROM

At this point you do a CBC with lytes which comes back as follows

CBC:  Hgb 12.1 and WBC 31.1  – the rest was WNL

Lytes: WNL

You go back and press this patient for more information…he says he has felt “the lump” in his neck for a few months now but he denies any cough, fever, vomiting, diarrhea and the only other info you get out of him is that he sometimes feels itchy all over.

You order a CXR because he has an elevated white count

Questions:

1) What is the likely Diagnosis in this patient?

  1. Hodgkins Lymphoma
  2. Acute Myelogenous Leukemia
  3. Acute Lymphoblastic Leukemia
  4. Pneumonia

2) What current infection (or previous history of infection) would increase the patient’s risk for this disease 5-25 times?

  1. Varicella Zoster
  2. Herpes Zoster
  3. Pertussis
  4. HIV

3) Which one of the following is NOT a common presenting symptom/sign for this disease?

  1. Painless lymphadenopathy of cervical region, axilla or groin
  2. Fever, weight loss and or night sweats
  3. Mediastinal mass causing mass effect symptoms like pain, pleural effusion or superior vena cava syndrome
  4. Pruritis and fatigue

Answers:

  1. A.  This patient likely has Hodgkins Lymphoma.  HL arises from germinal center or post-germinal center B cells and has a unique cellular composition, containing a minority of neoplastic cells (Reed-Sternberg cells and their variants) in an inflammatory background and can cause anemia and elevated white counts. HL has a bimodal age distribution curve. In the US and other economically advantaged countries, there is one peak in young adults (approximately age 20 years) and one in older age (approximately age 65 years); the majority of patients are young adults and there is a slight male predominance.  AML and ALL are close second options here due to similar early presentations, however, with AML, the median age at diagnosis is 65 years old and with ALL the vast majority of cases present between 2-5 years of age.  Bleeding disorders are more likely to be present and the cause of an initial presentation with these patients.
  1. D.  The incidence of HL is increased in a number of settings associated with immunodeficiency and infection. Among patients infected with HIV, the relative risk of HL is increased in various studies from fivefold to 25-fold. There also appears to be an increased risk of HL in patients with a history of infectious mononucleosis caused by Epstein Barr virus.  Interestingly, other childhood infectious illnesses including chickenpox, measles, mumps, rubella, and pertussis are negatively associated with the risk of HL.
  1. C.  A, B and D are all true.  Though a mediastinal mass discovered on routine chest x ray is a common presentation in an HL patient, it is NOT common to have any symptoms associated with it. The mass may be fairly large without producing local symptoms. Less commonly, the mass produces nonspecific symptoms such as retrosternal chest pain, cough, or shortness of breath. Small pericardial or pleural effusions are rare except in patients with bulky mediastinal disease. Superior vena caval obstruction is also rare.  Painless lymphadenopathy is present in as much as 80% of patients with HL.  Fever, weight loss and night sweats (the classic B symptoms), though not specific to HL, are present in less than 20 percent of patients with stage I/II Hodgkin lymphoma and up to 50 percent of patients with advanced disease.  Pruritus and fatigue, though not specific, can be early symptoms of the disease.  Pruritus specifically may be an important early symptom, preceding the diagnosis of HL by months or even a year or more. Pruritus occurs early in approximately 10 to 15 percent of patients, but the great majority of patients experience pruritus at some time during the course of illness. It is usually generalized and occasionally severe enough to cause intense scratching and excoriations.

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