Staff CPC 18/01/2023 @PGIMER, Chandigarh

Patient : Ms S, Age : 18 years, Resident : Chamba,Himachal Pradesh CR No: 202205180043

Date of admission : 13/12/2022 Date of death : 25/12/2022 Department : Clinical Haematology and Medical Oncology
Clinician In-Charge : Dr.Pankaj Malhotra Radiology Discussant: Dr. Nidhi Prabhakar
Clinical Discussant: Dr. Kushal Gupta Pathology Discussant: Dr.Debajyoti Chatterji
Cytology Discussant : Dr.Nalini Gupta /Dr. Gunjan Nuclear Medicine Discussant : Dr.Rajendra /Dr.Yamini
A) PRESENTATION AND HOPI :
Chief complaints: Fever x 2 months
Fatiguability x 2 months
Lower limb swelling x 10 days
Backache x 2 months
Background & History of Present Illness : Ms. S was apparently well till October 2022 when she developed
• Fever documented upto 104 F , with chills and rigor, intermittent, no diurnal variation, with weight loss(undocumented),
with loss of appetite and fatigue.
• Inguinal swelling since 1 months- insidious onset, gradually progressive, not painful or itchy or associated with pus
discharge.
• History of sensation of abdominal distension and abdominal pain present.
• Patient also developed both lower limb swelling –insidious in onset, progressive started from ankles then progressed to mid
thigh, no h/o redness , itching, pus discharge.
• Backache on and off since 2 months localized to waist bilaterally, no radiation to lower limbs, no h/o tingling and numbness,
• Sleep reduced. There is no history of night sweats , shortness of breath, orthopnoea, PND, jaundice, constipation,loose stools.
There is no h/o cough, hemoptysis, hematemesis, chest pain, palpitations, syncope, headache, LOC, AMS, Seizures.
Past history: No h/o TB, CAD, T2DM, HTN, BA, Epilepsy, or thyroid disorder
Personal history: Mixed diet , Normal sleep pattern, Normal bowel and bladder habits No addictions Unmarried
Family history: history of malignancy (CRC) in grandmother. No records. No h/o TB in family
Treatment history : Patient was admitted with above in Tanda (HP). No past records. Came to PGIMER.

B) EXAMINATION AND INVESTIGATIONS :

INV @ admn (Outside): 13/12/22
General examination. Systemic examination: Hb (g/dl) 9.5
GCS : E4V5M6, CVS: S1S2 normal. no murmurs.
TLC(x 109/L)/ DLC(N/L) % 5.5/(60/35)
At admission : Resp: b/l AE+, NVBS, no added
Platelets (x 109/L) 152
BP- 112/76mmhg sounds
Pulse- 100/min, regular Abdomen: soft, non tender Urea/Cr/ Uric acid (mg/dL) 17.5/0.68/ 5.0
RR: 22/min. no hepatosplenomegaly, bowel Na/K(mmol/L) 130/4.5
Temperature: 99.8⁰f sounds present Ca/Po4 (mg/dL) 8.5/4.38
Spo2- 97% CNS:- HMF : normal. no FND Bil (T/C)(mg/dl) 0.57/0.16
GPE : P+/Ic-/Cy-/Ed+ b/l LL/Club- AST/ALT/ALP (U/L) 20/9/54
/LN-Left inguinal+(NP)/ JVP - T.Prot/S.Alb (g/dL) 7.59/3.0*
PTI %/INR 90%/1.1
USG (outside) : s/o Left tubo-ovarian complex lesion, ? pyosalpinx
Tumour markers (outside) : AFP : 1.81, bHCG- 2.35, LDH : 293
Baseline Whole body PET-CECT Scan (12/12/22) Outside :- Left cervical level IV,V and supraclavicular regions, largest
2.0*1.3 cms (SUV max- 6.5); few LN in cardio-phrenic, diaphragmatic and left paravertebral regions. Wall thickening with increased
FDG uptake in sigmoid colon (max wall thickness 1.1 cms, (SUV max 3.7)). Multiple discrete and coalescent LNs seen in
porto-caval, retro-caval, pre-caval, para-caval, aorto-caval, pre-aortic, para-aortic, mesenteric, b/l common iliac, external iliac, pre-sacral,
sigmoid meso-colon, in the inter-muscular planes of left gluteal regions and b/l inguino-femoral regions (L- 4.7*4.1 cms (SUV max
17.2).Few ST density lesions with increased uptake in Lt. psoas, iliacus, posterior abdominal wall, Lt. erector spinae, & gluteal muscles.

C) INVESTIGATIONS @PGIMER : Hemogram

07/12/2022 (OPD) 13/12/2022 (IPD) 19/12/2022 (IPD) 23/12/2022(IPD)
Hb (g/dL)) 8.8 9.1 7.2* 7.0*
TLC(x 109/L) 5780 8600 13700 16200
N/L/E/M (%) 66/20/2/11 66/12/0.7/20 77/6/0/16 84/7/0/8
Platelet(x 109/L) 74* 185 142 78*
Normocytic, normochromic, decreased platelets, Elliptocytes,
P/S Platelet giant forms+ -
with few giant forms. anisocytosis

Tumour markers : Serum CEA :3ng/ml (<5) , Serum Ca-125- 95U/ml (<35)
 Biochemistry:
07/12/022 13/12/2022 19/12/2022 23/12/2022
Na+/K+ (mmol/L) - 130.9/4.50 126/4.30 123.7/5.51
Urea/Cr (mg/dL) 54.3/0.62 17.5/0.68 40/0.67 84.1/1.29*
Bil(T/D) (mg/dl) 0.5/0.39 0.57/0.16 0.39/0.06 0.47/0.31
ALT/AST/ALP (U/L) 18.2/37.2/38 20.4/9/54 7/16/- 28/13/75
T.Prot/Albumin (g/dL) 6.42/3.09* 7.59/2.92* 5.7/2.49* 5.83/2.04*
Mg+/Ca+2/PO4- (mg/dL) -/7.97/4.47 -/8.50/4.38 - 2.1/8.16/5.76
LDH (135-225U/L) 293* 539* - 229*
Others - - Amylase-27 U/L (28-100) CRP-177 mg/l (0-5)*

Coagulation profile: Viral-markers :

Date 23/12/2022 HBs Ag Non reactive
PTTK/aPTT(26-35sec) 33.8
Anti-HCV Non reactive
PT(12-15sec) /INR 23.6 /1.66
PTI(%) 58%* HIV Non reactive
Fibrinogen(2-4g/L)/d Dimer(0-240ng/ml) 5.29 /3601.7* Anti HBc total Negative

Blood Culture (BACTEC 39074; reported 29/12/2022) : Enterobacter hormaechei

Sensitivity :29/12/2022: S: Amikacin/Ceftazidime/Cefepime/Imipenem/Pip-Taz/Cefoperazone-Sulbactam ; IS : Ciprofloxacin
FNAC left supraclavicular LN( 19/12/22, Lab 7785 review):- Malignant neoplasm, morphologically s/o high grade lymphoma,
infiltration by leukemia. Advised repeat FNA @PGI to exclude carcinoma, and correlation with CBC and marrow findings.
USG Compression B/L legs (17/12/2022) : Morphed subcutaneous edema in left upper thigh and groin region with multiple discrete
conglomerate LN, obscuring left CFV and SFV, marked subcutaneous edema and overlying bandages.
USG B/L LOWER LIMB ARTERIAL DOPPLER(21/12/22):- biphasic waveform in b/l CFA, SFA, Popliteal , ATA, PTA .
diffuse skin and subcutaneous tissue edema seen in bilateral lower limbs.
LEFT INGUINAL LN BIOPSY and IHC (sent 16/12/2022) : Report not released
ECG (21/12/2022) : Normal
CT-PA (23/12/2022): No filling defect seen in Pulmonary Artery, and its right and left branches to suggest PTE. Gross right pleural
Effusion, with passive atelectasis of underlying lung parenchyma; minimal left pleural effusion. No pericardial effusion, mediastinal
or hilar LN; extensive fat stranding with fluid in right anterior and lateral chest walls.
2D-ECHO : 21/12/2022 : Tachycardia, EF-55-60%, No RWMA, AoFV : 0.9m/s
ECG : 24/12/2022 8pm : PSVT

D) COURSE IN THE HOSPITAL AND MANAGEMENT : Ms.S, was admitted on 13/12/2022 evening with fatigue, bodyache,
bilateral asymmetrical leg (R>L) and left inguinal swelling, no fever. The provisional working diagnosis was lymphoma (outside
reports). After sending preliminary blood investigations, including cultures (based on history), she was started on anti-TLS measures
(tab. Allopurinol 100mg TDS, hydration) and DVT prophylaxis (LMWH 40mg) on 14/12/2023. She had a fever spike of
Tmax-100.7F on 14/12/2022, which subsided with Tab Paracetamol. The outside FNAC smears were submitted for review, and she
also underwent an excision biopsy from left inguinal LN on 15/12/2022. She was started on steroid pre-phase (Prednisolone 100mg
OD x 5 day) on 16/12/2022 x 5 days. She was doing well and her blood showed constant increase in TLC (? steroid effect) and also
a marked improvement in platelets. In view of her asymmetrical limb swelling, and although she was on prophylactic anticoagulation,
due care was taken to rule out venous thrombosis (lower limbs) as well as PTE, in view of her raised d-dimer and fibrinogen levels
by doing limb sonographies and CT-PA (between 17/12/22 till 23/12/22). Except for the spike of fever (1 episode) on 14/12/2022, she
never recorded fever. She underwent ECG and 2DECHO on 21/12/2022 which were normal. On 23/12/2022, she had a T(max) on
99.1F, and a CRP (raised 177) along with decrease in platelets, and a derangement in renal parameters (U-84.1, Cr-1.29). On
24/12/2022 afternoon and evening she complained of uneasiness and palpitations, and was found to be hypoglycemic with trough
levels of 48mg/dl at 7pm, managed with D25%. An ECG was done which showed tachycardia due to PSVT, and she received Inj.
Adenosine 6 mg for rhythm and rate control. The PSVT reverted, but she had a second hypoglycemic episode at 2am on 25/12/2022,
which was managed with D25%. On the morning of 25/12/2022, the patient was comfortable. However, she again complained of
sudden uneasiness, losing consciousness suddenly, with loss of pulse and un-recordable blood pressures at around
10:45am.Hypoglycemia was ruled out.CPR (ACLS) was immediately initiated but she could not be revived. Postmortem blood
culture report (29/12/22) revealed sensitive strain of Enterobacter hormaechei.

E) FINAL DIAGNOSIS : High Grade NHL (B-Cell Lymphoma), Stage IV BE with Enterobacter hormaechei septicaemia, with
renal dysfunction, overwhelming sepsis with cardiogenic/refractory shock

F) CAUSE OF DEATH : Septicaemia related cardiogenic/refractory shock.