Challenging Case Presentation. Clinical History

Transcription

1 Challenging Case Presentation Clinical History By Yahia Ismail,MD,MRCP(UK) Medical Oncology Dept.,NCI 01/04/13

2 History of Present Illness(HPI) A 21-y-old single female was referred to NCI 7 months ago giving history of progressive recurrent epistaxis for almost 1 year duration. CT base of skull and nasopharynx revealed : large nasopharyngeal mass. Pathology of the Nasal Endoscopic-guided Bx revealed : NHL

3 Subsequent IPT confirmed DLBCL. No other symptoms reported. No abnormalities detected clinically. CT Chest/Abd/Pelvis was essentially normal. BMA&BMB were free of infiltration. The patient was assigned as DLBCL stage IAe.

4 The patient received 6 cycles of CHOP chemotherapy in the OPC. During the course of chemotherapy, patient experienced 3 episodes of Febrile Neutropenia that necessitated hospital admission for treatment with broad spectrum IV antibiotics & Growth factor support. F/U CT after 6 cycles of chemotherapy turned back to confirm achievement of CR. Confirmatory PET/CT was requested.

5 Three weeks after end of chemotherapy, the patient started to suffer from dizziness, nausea, rec. vomiting and progressive backpain. Two days later, the patient developed siezures with typical carpopedal spasm. Patient urgently referred to ICU, serum Ca was 0.7 mmol/l(2.8 mg/dl)!

6 PTH : 17.5 pg/ml (12-72) 25(OH)Vit D : 12.4 ng/ml (Defficient <20). Bone Scan showed diffuse inflammatory changes involving the whole spine. Despite starting intensive treatment for combating hypocalcaemia, patient continued to experience seizures.

7 CT brain revealed parenchymatous abnormalities. Subsequent confirmatory MRI revealed multiple ring-enhancing lesions involving basal ganglia surrounded by vasogenic edema. The DD of MRI results dominated the possibility of infection over lymphoma. Empirical ttt directed to combat bacterial &fungal brain abscesses was started right on admission.

8 Blood Culture: Negative for growth. CSF - Cytology: Negative for malignancy. -Gram stain: rare neutrophils & some gram +ve cocci - ZN stain : Negative. -Culture: Aspergillous Flavus? Contamination. Serum GMN: Negative. Toxoplasma IgG: Positive IgM: Negative

9 Despite ttt with liposomal AmphoB +Broad spectrum antibiotic+metronidazole, fever was not controlled with spikes (39-40C) for 7 days. On D8,the patient showed marked deterioration: GCS 8 Rt-sided weakness with extensor plantar response Rt UMN Facial palsy Urinary incontinence Urgent MRI brain documented progressive course of the intracranial lesions, edema & early hydrocephalic changes.

10 Consultation of ID consultant was carried out, he advised to: 1. Start urgently anti-toxoplasma therapy(septrin DS + Clindamycin). 2. Dehydrating agents(steroids + Furesomide). 3. Continuation of antifungal therapy(voriconazole). 4. Discontinue other antibiotics.

11 Twelve hours after starting ttt, patient improved marvelously: -GCS 15 -Complete recovery of all the neurological insults except mild residual UMN facial palsy. In the following 5 days, patient continued to experience excellent improvement with fever strictly controlled!!

12 PET/CT was done for further evaluation: -Negativity for any lymphomatous lesions. -The brain lesions are consistent with cereberal infection?toxoplasmosis! F/U MRI brain after 1 month of starting antitoxoplasma therapy confirmed marked regressive course.

13 Discussion of the case in the Medical Oncology scientific meeting recommended to explore the possibility of HIV. Unfortunately, HIV Ab test was POSITIVE. Confirmatory PCR was also POSITIVE. The patient referred to HIV Unit in a governmental hospital to start HAART.

14 PMH Tonsillectomy at age 10 Appendecectomy at age 12 History of Blood Transfusion Patient received 3 units PRBCS 2 months ago. Family History No relevant FH of medical significance.

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