WELCOME

TO

GRAND ROUND
PRESENTATION
 PRESENTED BY
DR. MD. JAFAR ISLAM
MD(PHASE-A), INTERNAL MEDICINE
SIR SALIMULLAH MEDICAL
COLLEGE MITFORD HOSPITAL
 PARTICULARS OF THE PATIENT

Name: Md. Al Amin

Age: 22 years
Sex: Male
Marital status: Unmarried
Religion: Islam
Occupation: Labourer
Present Address: Dholaipar, Dhaka
Date Of Admission: 05/09/2019(Through
Emergency)
 CHIEF COMPLAINTS

 Loose motion for 5 months

 Abdominal pain for 4 months
 Fever for 4 months
 HISTORY OF PRESENT ILLNESS

According to the statement of the patient he was

alright 5 months back, then he developed loose
motion, which was 6-8 times in a day, watery, non-
voluminous, foul smelling, occasionally it contain
mucus but does not associated with passage of
black tarry stool or per rectal bleeding. It is not
aggravated by taking milk or dairy product, bread
or leafy vegetable.
 HISTORY OF PRESENT ILLNESS

The patient also complaints of episodic abdominal

pain more marked in right iliac fossa. The pain is
gradual onset, colicky in nature, moderate to
severe in intensity, does not radiating to any
specific site, aggravated by taking food, not related
to any drug or posture change.
 HISTORY OF PRESENT ILLNESS

For the last 4 months the patient also suffering

from fever. The fever is low grade, intermittent,
does not comes with chills and rigor, subsides
spontaneously with sweating. The fever is more
marked in the evening part of day. Highest
recorded temperature is 100 °F
 HISTORY OF PRESENT ILLNESS

On query patient also gave history of gradual loss

of his body weight for last 5 months. The patient
said that he lost about 9 kg of his previous body
weight during the time of his illness which is
unintentional, evidenced by loosening of his daily
garments and associated with loss of appetite.
 HISTORY OF PRESENT ILLNESS

Patient give no history of vomiting, cough,

coughing out of blood, contact with known
smear positive pulmonary TB patient, itching,
generalized nodular swelling, heat intolerance,
oral ulcer, joint pain, skin rash.
 HISTORY OF PRESENT ILLNESS

Patient was admitted in this hospital 3 months

back with the same complaints, he was then
investigated properly but failed to reach a
definite diagnosis and discharged with
symptomatic treatment.
 HISTORY OF PAST ILLNESS

There is no significant past medical or surgical

history
 FAMILY HISTORY

He lives with his parents who are in good

health. He has one brother and one sister. His
sister has been suffering from Acute myeloid
leukaemia who is currently under treatment in
BSMMU.
 SOCIO- ECONOMIC HISTORY

Comes from a family with middle socio-

economic condition. Lives in paka house, drinks
arsenic free tube-well water and use sanitary
latrine.
 PERSONAL HISTORY

Smoker for 8 years. Non alcoholic.

No history of intravenous drug abuse or
explicit sexual exposure.
 IMMUNIZATION HISTORY

He is immunized according to EPI schedule.

 GENERAL EXAMINATION

 The patient is looking ill and depressed

 Poor nutritional status
 There are generalized clubbing involving fingers

and toes
 Leukonychia present
 No anemia, jaundice, oedema and

lymphadenopathy
 Pulse- 80/min
 BP- 100/60 (No postural drop)
 Temperature- 98 °F
 GASTROINTESTINAL SYSTEM

 Oral cavity, lips and gum:

Appears normal
 Abdomen :
Inspection: Normal in size and shape
Palpation: Tenderness present over right iliac fossa,
there is no palpable mass, no organomegaly.
Ascites: Absent.
 Per-rectal examination:
Inspection: No peri-anal tags or fistula or abscess.
Digital rectal examination: No abnormality detected
 OTHER SYSTEMIC EXAMINATION

 Reveals normal findings

 SALIENT FEATURE

Md. Al Amin, 22 years old, Unmarried, labourer, normotensive,

non-diabetic, smoker hailing from dholaipar, presented with

loose motion for 5 months. It is watery, non-voluminous, foul

smelling, sometime contain mucus but not blood. He also

complaints of abdominal pain more marked in right iliac fossa

which is gradual onset, colicky in nature, moderate to severe in

intensity, aggravated by taking food.

.
 SALIENT FEATURE

For the last 5 months the patient also suffering

from low grade intermittent fever with evening
rise of temperature. Patient also gave history of
gradual loss of his body weight for about 9 kg
during the time of his illness. Patient give no
history of vomiting, cough, oral ulcer, joint pain,
skin rash.
 SALIENT FEATURE

On general examination patient is looking ill,

generalized clubbing and leukonychia present.
Per abdominal examination reveals diffuse
tenderness all over abdomen specially over right
iliac fossa. Other systemic examination reveals
normal findings.
Provisional Diagnosis?
 PROVISIONAL DIAGNOSIS

 INTESTINAL TUBERCULOSIS
 DIFFEERENTIAL DIAGNOSIS

 Inflammatory Bowel Disease, more likely to be

Crohn’s disease
 Lymphoma
INVESTIGATIONS
 INVESTIGATION

Investigation First Admission This Admission

Complete Blood Count
Hb 13.30 g/dl 12.10 g/dl

WBC 16,050/cumm 12,480/cumm

N-83% L-13% N-83% L-12%
ESR 22 15
PBF - Normal
Chest X-Ray - Normal
S.creatinine 0.7 mg/dl 0.8 mg/dl
RBS 5.8 mmol/L 6.5 mmol/L
Stool R/E - Mucus: +
Fat Globules: +
Vegetable cells: +
 INVESTIGATION
Investigation First Admission This Admission

S. Albumin - 2.34 gm/dl

TSH 1.05 mIU/mL -

SGPT 17 U/L -
MT test - Negative
HBsAg Negative -
Anti HCV Negative -
Anti HIV1,2 Negative -
Tissue 10.2(Negative) -
Transglutaminase
 INVESTIGATION

 Chest X-ray
 INVESTIGATION
 COLONOSCOPY (24/06/2019):
 Seen up to terminal ileum
 Peri-anal area: Normal
 Anal canal: Normal
 Caecum and terminal ileum:
Terminal ileum shows diffuse ulcero-nodular lesion which
causing distortion of the ileo-caecal valve. A large ulcer
also seen at the ascending colon. Multiple variable size
polyps seen in the caecum and ascending colon. The
mucosa, vascular pattern and the lumen of the
transverse, descending colon and sigmoid colon
including the rectum and anal canal appear normal.
 INVESTIGATION

 Endoscopy of upper GIT (19/06/2019):

 Oesophagus and stomach-appear normal

 Duodenum-Bulb shoes multiple small ulcers.

Post bulbar area also shows few small ulcers.
INVESTIGATION
Histopathology report(25/06/2019):
Microscopic description:
Sections show colonic mucosa. The lamina propria shows
dense infiltration of mature looking lymphoid cells. The lining
epithelium is intact in most of the areas. The lymphoid cells
have destroyed the normal architecture in some area.
Diagnosis:
Lymphoproliferative disorder. Need exclusion of lymphoma by
immunohistochemistry.
 Immunohistochemistry report (20/07/2019):

Result:
CD45: Positive
CD3: Positive in T-lymphocytes distribution
CD20: Positive in B-lymphocytes distribution
CD79 alpha: Positive in B-lymphocytes distribution
Pancytokeratin (AE1/AE3): Negative in tumour cell
CD10: Negative
Ki67: 3%

Diagnosis:
Lymphoid hyperplasia
INVESTIGATION
Ultrasonography Report(04/09/2019):

Comment:
Multiple enlarged lymph nodes are noted in para-
aortic region and within the mesntery.
INVESTIGATION
FNAC of mesenteric lymph node(10/09/2019):

Microscopic examination:

Smear show mixed population of lymphoid

cells present dispersedly. The background
shows small number of normal appearing
epithelial cells and blood.

Possibility of non-Hodgkin lymphoma may be

explored.
INVESTIGATION
? CONFIRM DIAGNOSIS ?
THANK YOU