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Case of M3

5/23/12

First seen 1 year back, in March, 2011 41 year old unmarried lady presented with: fever

pain left breast, right lower chest Fever low grade, more in evening Chest pain pleuritic type

milky discharge from bilateral nipples

1 month

Loss of weight, loss of appetite present

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No history of headache, visual disturbance

Bilateral varicose vein surgery 2003 Excision left breast lump 2005, Appendicectomy 2007

Family history of tuberculosis (Mother 25 yrs and brother 8 yrs back)

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Pale. No axillary LNE. Left breast tender, no palpable masses felt Chest :clear CVS NS :S1,S2 normal :No FND, Visual field normal

GIS : P/A soft, non tender. No organomegaly or ascites

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ESR 60mm/ 1st hour S. prolactin (14/03/2011) 65.26ng/mL (1.4 24.2) USG Breast (15/03/2011) fibroadenotic changes both breasts CT Brain (21/03/2011) contrast normal Mantoux (23/03/2011) plain and 8mm

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MRI Brain (07/04/2011)

Normal

USG Abdomen (30/03/2011) A small, well defined hypoechoic lesion about 2.6x 1.6 cm, medial to 2nd part of duodenum anterolateral to IVC - ?lymph node, ? paraaortic mass. Suggest CECT

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CECT Abdomen(19/04/2011) Right pleural effusion, ?fibrosis, few nodules left base of lung; porta hepatis node ?cause - ? Kochs. suggested pleural fluid aspiration and cytology USG abdomen (20/04/2011) 9mm hypoechoic lesion s/o hemangioma in Right lobe of liver. Lymph node noted at porta. Very minimal pleural effusion right side. Not enough to aspirate
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At this stage, the patient was provisionally diagnosed as Right tuberculous pleural effusion, hyperprolactinemia and empirically started on Cat I ATT

(hyperprolactinemia : ?chest wall irritation due to pleuritis) Advised colonoscopy, not done

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One week after starting ATT, she was admitted to JMMC hospital with fever, abdominal pain and vomiting. There, DOTS regime was changed to AKT4. She improved with treatment and was discharged. Fever, breast discharge subsided, appetite improved with ATT
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USG Abdomen (01/05/2011) Hepatomegaly, single right paraaortic lymph node-?tuberculous, grade II hydroureteronephrosis left side-?left midureteric calculi. Discontinued Anti tuberculous drugs after 3 months due to abdominal pain and vomiting
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ANA(01/06/2011) Negative TFT (09/07/2011) WNL APLA antibody (12/07/2011) IgG, IgM negative

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USG Abdomen (15/07/2011) hepatomegaly, multiple left inguinal lymphadenopathy with soft tissue plane oedema left mid thigh region OGDscopy(15/07/2011) oesophagitis, antral gastritis
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In August 2011 (6 months after initial symptoms) she got admitted in AIMS hospital with diffuse abdominal pain, mainly over right flank and recurrent vomiting almost immediately after food intake

MDCT abdomen urothelial carcinoma with ? lung metastasis, tuberculosis left ureter

Urology consultation done

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Urine AFB( 3 specimens), urine cytologyNegative

Readmitted in AIMS, October 2011 with pain, swelling, over right angle of mandible since 1 week. On examination, had tender submental, submandiblar and cervical LNE, largest measuring 20x9 mm. Treated with levofloxacin, continued ATT and supportive measures, symptoms resolved by the time of discharge, after 2 weeks.

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In December 2011, readmitted in AIMS with lower abdominal pain, dull aching in nature, more on the right side, radiating to flanks, aggravated by food intake and associated with 34 episodes of non projectile vomiting.

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O/e: pale; firm, mobile, non tender LNE in submental, submandibular, cervical and inguinal areas. P/a: tenderness in RIF and hypogastrium; a oval mass 5x5cm size, with ill defined margins, palpable in RIF.
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USG abdomen (24/12/2011- 4 months into Cat II ATT) thickened bowel loops with minimal free fluid in RIF, multiple enlarged lymph nodes in RIF. Advised MDCT abdomen with contrast and LN biopsy RIF. DAMA due to financial constraints
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Admitted at MCH, Thrissur on 29/12/2011 as pain abdomen, vomiting and loss of weight (>23 kg over 6 months) S.cortisol 30.32mcg/dl (normal) U.cortisol normal

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Echo (to rule out infective endocarditis) (05/01/2011) WNL USG abdomen(06/01/2011) Hepatomegaly, bilateral hyperechoic kidney, mild hydronephrosis. RIF obscured by bowel gas
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Now, 1 year after the initial symptoms, she presented with abdominal pain for the last 3 weeks Pain dull aching in nature, almost immediately after food intake. Pale, emaciated. Bilateral inguinal lymphadenopathy present
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PR 80/min, BP 80/60mm Hg

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S. T/D HbBr 10.2 0.6/0.4 SGOT/PT/ALP TC 15400 21/17/302 UKB, Urine PBG DC P74L24E2 Negative HIV, 4.1lakh Plt HBsAg, HCV S. Amylase ESR 142 - 35 RFT Normal RBS 286 Negative

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Peripheral smear : Relative neutrophilia with slight shift to left OGDscopy, Colonoscopy : Negative Biopsy taken from Ileocaecal valve showed colonic mucosa with foci of dense lymphocytic infiltration
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Awaited:

D2 biopsy - to rule out Crohns LN biopsy - to rule out lymphoma

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Present diagnosis : Abdominal TB Could it be MDR TB? Could there be an alternative diagnosis?

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