Surgery Case Presentation

Hodgkin's Lymphoma

BY:
Boppe Sai Amruth -180101039
Rishi Popat - 180101025
Rasya Reddy - 180101053
Case:
A 25 year old female complained of
multiple bilateral swellings at her
neck, axilla and groin.
She also has an abdominal lump.
Name: Kumari
Age: 25
Sex: Female
Occupation: Student
Address: Karkala

Chief Complaints:

- Fever since 1 month.

- Multiple Swellings on both sides of Neck since 1 month, Axilla since 3 weeks and Groin since
2 weeks.
- Presence of Itching on the face since 1 weeḳ
History Of Presenting Illness:
Patient was apparently asymptomatic 1 month ago when she developed Fever,
Swellings/Lumps and also Itching of the face.
- H/o Fever since 1 month that was sudden in onset, is intermittent in nature, high
grade and not associated with chills or rigor. No aggravating factors and relieved on
taking paracetamol but always recurred the next day.
- Sites of Swelling: B/L regions of the Neck, Axilla, Groin and Abdomen.
- Onset: Neck swellings since 1 month, Axilla since 3 weeks, Groin and abdomen since
2weeks. Insidious in onset, gradually progressive.
- Character: There was no pain or tenderness present
- The swellings were present continuously and there were no aggravating or relieving
factors.
- It wasn’t associated with any other factors and patient didn’t have any difficulty in
mobility.
- Patient complained of itching since 1 week that was present on the left cheek. It was
insidious in onset gradually progressive, didn’t have any aggravating factors and was
relieved on taking anti-histamines.
- No h/o of night sweats, weight loss, fatigue, dyspnoea or cough.
Past History:
- The patient was diagnosed for Infectious
Mononucleosis at a government hospital 5 years ago
after persistence of debilitating symptoms.
- No h/o diabetes, Hypertension, Tuberculosis, COPD,
Asthma, Cardiovascular disease or trauma.

Treatment history:
- The patient was treated for Infectious Mononucleosis at a
government hospital 5 years ago.
- No other significant treatment history.

Family history
- Not significant
Personal history:
- Patient has a mixed diet with normal appetite.
- Normal bladder and bowel habits
- Normal sleep
- No other history of alcohol consumption, smoking or
substance abuse.
Differential Diagnosis:
- Hodgkin's Lymphoma, , Non Hodgkins, Lymphoma
Tuberculosis, HIV, Chronic Lymphatic Leukemia, Non
specific lymphadenitis, Sarcoidosis, Secondaries in
lymph node.

Provisional Diagnosis:
- Hodgkin's Lymphoma
General Physical Examination:
• General examination
• Patient is conscious,cooperative and oriented to
time,place and person.
• Pt is moderately built and well nourished
• Bp- 110/70 mmHg
• Pulse- 75 bpm
• RR- 15
• Temp - 103 F ( 39.4 C)
• Pallor - negative
• Icterus - negative
• Cyanosis - negative
• Clubbing - negative
• Lymphadenopathy- present
Local Examination:
Inspection:
• Swellings- Number and Position- there are 4 swellings in the cervical, 3 in
axillary and 2 in inguinal regions. There is also presence of an abdominal
lump in the upper left quadrant.
• Cervical Swelling
• Skin over the swelling- there is no change in the color or presence of any
scars,ulcers or sinuses.
• Shape- the swellings are spherical in shape.
• Surface- smooth and discrete
• Edge- it is clearly defined
• Pulsations- no visible pulsations of the swellings
• Movement on deglutition- there is no movement on deglutition
• Movement on protrusion of the tongue- No movement
• Pressure effects of lymph nodes - There is deviation of the tongue towards
the left side on protrusion. No venous engorgement or swelling of the face.
Local Examination:
Inspection:
- Axillary Swelling
- Skin over the swelling- there is no change in the color or presence of any scars, ulcers
or sinuses.
- Shape- the swellings are spherical in shape.
- Surface- smooth and discrete
- Edge- it is clearly defined
- Pulsations- no visible pulsations of the swellings
- Pressure effects of lymph nodes - There is no edematous changes in the upper limb.
- Inguinal Swelling
- Skin over the swelling- there is no change in the color or presence of any scars, ulcers
or sinuses.
- Shape- the swellings are spherical in shape.
- Surface- smooth and discrete
- Edge- it is clearly defined Impulse on coughing- there is no impulse
- Pulsations- no visible pulsations of the swellings
- Pressure effects of lymph nodes - There is no edematous changes in the lower limb.
Local Examination:
Inspection:
Abdominal Swelling Skin over the swelling-
there is no change in the color or presence of any
scars,ulcers or sinuses.
Shape- the swellings is ovoid in shape.
Surface- smooth Edge- it is clearly defined
Impulse on coughing- there is no impulse
Movement with respiration- the abdominal swelling moves
with respiration.
Pulsations- no visible pulsations of the swellings Peristalsis-
no visible peristalsis of the abdominal lump
Palpation:

Cervical Swelling 
 Temperature- no change in temperature
 Tenderness- no pain or tenderness over the swelling
 Shape- spherical
 Surface- Smooth and discrete
 Edge- well defined
 Consistency - firm and rubbery
 Fixity to skin - the swellings are mobile and not fixed to the overlying skin
 Pulsations- no pulsations
 Fluid thrill- negative
 Reducibility - negative
 Compressibility - negative
- .
Palpation:
Inguinal Swelling
 Temperature- no change in temperature
 Tenderness- no pain or tenderness over the swelling
 Shape- spherical
 Surface- Smooth and discrete
 Edge- well defined
 Consistency - firm and rubbery
 Fixity to skin - the swellings are mobile and not fixed to the overlying skin
 Impulse on coughing- there is no impulse
 Pulsations- no pulsations
 Fluid thrill- negative
 Reducibility - negative
 Compressibility – negative
Palpation:
Abdominal Swelling
 Temperature- no change in temperature
 Tenderness- there is presence of pain
 Shape- ovoid
 Surface- Smooth
 Edge- well defined
 Consistency - soft
 Impulse on coughing- there is no impulse
 Fixity to skin - the swellings is not fixed to the overlying skin and immobile
 Fluid thrill- negative
 Pulsations- no pulsations
 Reducibility - negative
 Compressibility - it is compressible
 
Percussion - Dull note heard.
 
Systemic Examination
 
 CVS examination - S1 S2 heard, no murmurs heard
 Respiratory examination - NVBS heard
 Abdominal examination - splenomegaly is present, hepatomegaly absent
 Diagnosis:
Hodgkins Lymphoma – Nodular Sclerosis Type.
 INVESTIGATIONS
1. Blood
• Hb% - anaemia
• TC/DC- lymphocytopenia, monocytosis and eosinophilia
• Serum ALP - increased if bone/ liver involved
2. Imaging
• CXR P/A view, CT abdomen, lymphangiograpy
3. LN biopsy
• RS cells, fibrosis and necrosis
4. Bone Marrow, liver, mediastinal LN and spleen biopsies
• RS cells
 TREATMENT

• Chemotherapy and/or radiation therapy

• Antiemetics/ antidiarrhoeal drugs, sedatives
• Bone marrow transplant
• Blood transfusion
• Immunotherapy
CHEMOTHERAPY
 COMPLICATIONS

• Autologous bone marrow transplantation can cure half of patients who fail
effective chemotherapy regimens
• Because of the very high cure rate in patients with Hodgkin's disease, long-
term complications have become a major focus for clinical research.
• The most serious late side effects include secondary malignancies, cardiac
injury, infertility and Lhermitte's syndrome
Hodgkin’s Lymphoma:
-It is the most common type of lymphoma.
-Can be due to EBV infection or monoclonal B cell disorder.
-Characterized by presence of Reed Sternberg Cells that are giant cells with two large mirror image like nuclei among a background of other
lymphocytes.
-There are 2 stages –
Stage B- Presence of fever, night sweats, weight loss that has poorer prognosis.
Stage A- Absence of these symptoms and signifies better prognosis.