A 40 year old female presented with abdominal pain

Grand round

1. Dr. Shekh Abdullah al Mukit Phase A, Resident, Clinical Oncology A 40-Year-old Female presented with Abdominal Pain

2. Particulars of patient Mrs. Amena 40 Years Hypothyroid Non Diabetic, Normotensive Hailing from : Chandpur Date of Admission: 25/02/2024

3. Chief Complaints: Abdominal pain for 4 months

4. The patient developed diffuse abdominal pain which was insidious onset, gradually progressive, involved the whole abdomen, dull aching, initially mild to moderate but now become severe, no radiation, No specific triggering factor relieved by taking antispasmodic and sometimes bending forward. The pain was associated with nausea. The patient complained of constipation for last 1 month. She complained of passage of hard stool 1-2 days apart. She also complained of anorexia and weight loss which was not documented. PRESENTING ILLNESS

5. Course of illness With these complaints patient Went to a local doctor in Chandpur where she underwent several investigations and referred to Dhaka for further management

6. No H/O Fever Cough, Shortness of breath Palpitation or chest pain Jaundice Haematemesis, melena Itchiness, Joint pain, rash, photosensitivity per-rectal bleeding. nodular swelling, drenching night sweats, Leg swelling Contact with smear-positive active TB patient

7. Past medical history Newly diagnosed as a case of hypothyroidism

8. Clinical Examination

9. General examination Appearance : normal Body built : Average Pulse: 84 b/m , regular BP: 110/70 mmHg Temperature : 98.4 Degree F R/R :20 breaths/ min Mildly anaemic , not icteric

10. Clubbing, koilonychia- absent Lymph node not enlarged Thyroid gland not enlarged Bony tenderness absent No edema Skin condition normal

11. Systemic examination Abdomen-Abdomen is distended, umbilicus centrally placed and inverted. On palpation, abdomen is firm to hard, diffusely tender. No palpable mass. No organomegaly. Ascites absent. Bowel sound present. Other systemic examinations revealed no abnormalities.

12. Investigations

13. cbc CBC 16-03-2024 25/02/24 Hemoglobin (g/dL) 9.0 9.2 ESR mm in 1 st hr 45 120 RBC mill/ cmm 3.6 3.94 WBC 15.5 * 10^9/L 15.0 * 10^9/L Neutrophil (%) 73 66 Lymphocyte (%) 21 28 Platelet/ cmm 585,000 600,000 HCT 29.8% 31.5 MCV fl 82.8 79.9 MCH pg 25 23.4 MCHC g/L 30.2 29.2 RDW-CV 19.5% 14.9

14. Pbf findings 25.02.24 RBCs: Microcytic hypochromic WBCs: Increased, Mature, prominent cells are neutrophil Platelets: Increased Comment: Microcytic hypochromic anemia with neutrophilic leukocytosis and thrombocytosis

15. Investigations 26/02/24 15/3/24 CRP 25.6mg/L 15.72mg/L S. Creatinine (mg/dl) 0.85mg/dl S. Electrolytes ( mmol /L) Na+ 137mmol/L K+ 4.3mmol/L Chloride 107mmol/L

16. Investigations LFT 26/02/24 SGPT 10U/L SGOT 22U/L Albumin 41gm/L Total protein 80gm/L ALP 128U/L LDH 219U/L

17. Investigations Test Result TSH 19.92microIU/ml ECHO Normal Tuberculin test 20 mm RBS 4.5 mmol /L HBsAg Negative Anti HCV Negative HIV 1&2 Negative

18. Tumour markers

19. USG done outside BSMMU

20. Chest Xray

21. CT scan of abdomen with contrast

22. Impression Diffuse long segmental circumference wall thickening involving jejunum and ileum with mesenteric lymphadenopathy - possibly non-Hodgkin’s lymphoma Ddx - intestinal tuberculosis

23. Ba- meal of small intestine and follow through

24. Ba- meal of small intestine and follow through

25. Ba- meal of small intestine and follow through

26. Abdominal Xray on 10/03/24

27. Abdominal Xray on 02/04/24

28. USG guided core biopsy from abdominal lymph node Specimen: USG guided core biopsy from abdominal lymph node Gross description: received in Formalin are six linear friable grey-white core pieces of tissues. The largest one is 1.0 cm and the smallest one is 0.3 cm. Submitted in five blocks Microscopic appearance: Section shows linear tissue cores. these reveal a diffuse proliferation of atypical lymphoid cells. Areas of necrosis are seen Diagnosis: Atypical lymphoid hyperplasia/ Non- Hodgkins lymphoma

29. USG guided core biopsy from abdominal lymph node

30. Immunohistochemistry

31. DIAGNOSIS: Provisional Diagnosis Abdominal TB with Hypothyroidism with esophageal candidiasis Differential Diagnosis: Lymphoma with Hypothyroidism with esophageal candidiasis

32. Current status Patient is having severe abdominal pain almost everyday We started anti TB medication with steroid (19/3/24) but no improvement so far Surgery referral given, answer is pending

33. On going Rx Tab. Rimstar 4FDC 4+0+0 (Started from 19/03/24) Inj. Dexamethasone 1 vial i /v 12hrly Cap. Fluconazole (200mg) 0+1+0 Tab. Thyrin (25mg) 2+0+0 Tab. Algin (50mg) 2+2+2 Tab Amitriptyline (10) 0+0+1 Tab. Esomeprazole 20mg 1+0+1 Tab. Ondansetron (8) 1+1+1 Tab. Clonazepam (0.5) 0+0+1 Syp Lactulose 2TSF TDS

34. Problem list What is the diagnosis? What is to be done next?

35. Thank You