Grand round case presentation of a 60 years old female with fever and anemia.pptx

Grand round case presentation . New england journal style . Liposarcoma, dedifferentiated
Bantroptox 13th szmch bogura

1. Missing the target - A patient with Fever & anaemia Dr Seebat Masrur FCPS trainee Department of Medicine, SZMCH

2. Mrs. Rasheda Parvin, 60-yrs-old,Housewife Hailing from Upashahar , Bogura got admitted into this hospital on 19 th July 2025 Known case of Hypertension, Diabetes Mellitus, CKD, Hypothyroidism

3. Fever for 1 month. Fatigue for 1 month. A swelling behind left thigh for 6 months.

4. One month prior to admission into SZMCH

5. Fever for 1 week. low grade, continued, no evening rise, without any chills & rigors, 101°F, no travelling history Fatigue for same duration Insidious, progressive, hampering her daily household chores. Swelling behind left thigh for 6 months USG and Contrast MRI of thigh - Hemangioma

6. Investigation(6 th July 2025) HB% 6.7 gm/dl ESR 68 mm in 1 st hr TC 22000 Neutrophil 87% MCV 78 fl /L Platelet 488000 S. Creatinine 1.9 mg/dl(eGFR 27ml/min/1.73 m2) RBS 13 mmol/L U/R/M/E Normal CXR Bilateral Pulmonary Infiltrates

7. After initial investigations, the patient was treated with Injectable antibiotics 3 units of blood and Supportive care. Showed partial clinical improvement and was discharged from the local clinic with a diagnosis of LRTI with Haemangioma with anaemia under evaluation.

8. Five days following discharge

9. Persistence of low-grade, continued fever Increasing pallor New-onset jaundice No history of pale stool, pruritus, abdominal distension, nausea, vomiting, gastrointestinal bleeding, or features suggestive of hepatic encephalopathy. Cough Dry, occasional mucoid expectoration

10. Repeat labs: (16 th July 2025) HB% 7.6 gm/dl ESR 72 mm in 1 st hr TC 26000 Neutrophil 90% MCV 79 fl /L Platelet 495000 S. Creatinine 2.0 mg/dl S. Bilirubin 10 mg/dl Liver Enzymes Not done

11. Referred to Hepatology Department of SZMCH 19/07/2025

12. Her complaints were- Low grade persistent fever Jaundice Anaemia Left thigh swelling

13. Managed with intravenous antibiotics(Meropenem & Levofloxacin) Jaundice improved. Fever persisted. Anaemia worsened, requiring further 4-units fresh blood transfusion. Hematology consultation obtained → Hemolytic anaemia suspected → comprehensive work-up initiated.

14. Investigation(20 th july 2025) Test Name Result Hb% 6.3 g/dl ESR 85 mm in 1 st hr TC 31,000 / uL Neutrophil 88% MCV 84 fL Platelet 541,000 /uL S. Creatinine 1.8 mg/dl

15. Investigation(20 th July 2025) PBF: Neutrophilic Leukocytosis , Microcytic anaemia, Thrombocytosis Reticulocytosis (3.47%) Indirect Coombs Test: Positive Direct Coombs Test: Negative

16. Investigation Result RBS 18 mmol/L SGPT 31 U/L ALP 822 U/L Total Bilirubin 10.79 mg/dl Direct bilirubin 8.38 mg/dl Indirect Bilirubin 2.41 mg/dl LDH 211 U/L U rea 47 mg/dl

17. Investigation Result Stool for OBT Negative Serum Calcium 8.3(mg/dL) Sodium 126(mmol/L) Potassium 3.6(mmol/L) Ferritin (ng/mL) 4,160 (15.07.25) → 10,600 (21.07.25) Protein Electrophoresis Polyclonal hypergammaglobulinemia with marked hypoalbuminemia

18. At that stage, the patient received another two units of cross-matched blood. (27/07/25) Value S. Bilirubin 1.72 mg/dl Hb% 9.6 gm/dl TC 26250 u/L

19. At that time multidisciplinary medical board was conducted and decision was made to transfer her to Medicine Department of SZMCH for further evaluation.

20. In Medicine Department ( 28 th July)

21. Fever —for 1 month Persistent anaemia — requiring repeated transfusions Swelling over left posterior thigh — gradually increasing in size for 6 months, initially painless later on became mildly painful, no trauma or discharge.

22. Worsening cough with exertional breathlessness; no orthopnoea or PND. Weight loss of 5 kgs within this period of her illness.

23. There was no history of syncope, palpitations, urinary symptoms, joint pain, rash, oral ulcers, photosensitivity, lymphadenopathy, altered sensorium, jaundice in the past, hematemesis, or melena. She remained compliant with medications for her comorbidities — diabetes, hypertension, CKD, and hypothyroidism.

24. General Examination Appearance: Anxious & ill-looking Body Build & Nutrition: Average Severely Anaemic , Not Icteric Temperature: 100.4 °F Pulse: 104 /min, regular. Blood Pressure: 140/80 mmHg Respiratory Rate: 24 Breaths/min SpO₂: 96% on room air No clubbing, cyanosis, leukonychia , koilonychia . Lymph nodes: not palpable No edema or dehydration Thyroid not palpable No bony tenderness JVP not raised

25. Abdomen Liver palpable 2 cm. No other organomegaly No palpable intraabdominal lymphadenopathy. Shifting dullness absent.

26. Examination of Left Lower Limb Ill-defined swelling, posterior aspect of thigh, ~6 × 5 cm, firm, mildly tender, normal overlying skin, no visible veins. Peripheral pulses were present.

27. Respiratory System Few fine crepitations in both lower zones. All other systemic examinations reveals no abnormality.

28. Diagnostic work-up

29. Parameter Clinic Hepatology Medicine Hemoglobin (g/dL) 7.6 9.6 6.2 WBC (×10⁹/L) 26 26 34 Platelets (×10⁹/L) 488 526 510 ESR (mm/1st hr ) 72 4 5 7 8

30. Parameter Clinic Hepatology Medicine Total bilirubin (mg/dL) 10 10.8 1 .72 ALP (U/L) - 822 Albumin (gm/L) - — 27 LDH (U/L) - 211 151

31. Parameter Clinic Hepatology Medicine S. Creatinine (mg/dl) 1.9 2.0 1.95

32. Parameter Result CRP (mg/L) 304 mg/L Ferritin (ng/L) 10600 μ g/L ANA Negative ECG Sinus tachycardia with LVH NT pro BNP 3665.50 pg /ml Bone Marrow Study Features Suggestive of Myeloid Hyperplasia

33. Test Result Viral & Parasitic Screen HBsAg, HCV, Kala-azar, Malaria, Leptospira ab in urine – Negative Sputum for AFB & Gene Xpert MTB/RIF Negative Blood/Urine Culture Negative Urine R/M/E Proteinuria(2+), Pus cells(8-10/HPF), RBCs (0-1)

34. Investigations Findings USG of W/A Hepatomegaly, Bilateral Renal parenchymal Disease MRCP Hepatomegaly, Splenomegaly CXR P/A View Bilateral inflammatory opacities Echocardiography Concentric LVH, Mild MR, EF 65% Endoscopy Bile Reflux Colonoscopy Rectal Polyp(Polypectomy done)

35. Pyrexia of Unknown Origin & left thigh Hemangioma & DM & HTN & CKD & Hypothyroidism & Anaemic heart failure

36. Treated with intravenous Ceftriaxone, Meropenem, Metronidazole, Levofloxacin. The patient became progressively lethargic and dyspnoeic. Decision was made to transfer her to Medicine Department of BMU.

37. Discussions

38. Differential diagnosis Leptospirosis Pneumonia Hemophagocytic syndrome Septicemia Leukemia SLE

39. Investigation Findings Bone Scan Solid Avascular Cold Area Upper Medial Part of Thigh

40. In Bangladesh medical university

41. Diagnostic Workup (Mid Aug-Sep)

42. Parameter S ZMCH B MU Hemoglobin (g/dL) 6.2 7 .3 WBC (×10⁹/L) 34 2 6.5 Platelets (×10⁹/L) 510 3 25 ESR (mm/1st hr ) 7 8 100

43. PBF 24/08/25 Dimorphic RBC Mature WBC with increased total count and Neutrophil Normal platelet count Bone marrow 25/08/25 Features Suggestive of Myeloid Hyperplasia.

44. Test SZMCH BMU Bilirubin Total 1 .72 mg/dL 1.8 mg/dL Procalcitonin - 20.62 ug/L Ferritin 10600 μ g/L 12784 n g/ml ALP 822 U/L 2110 U/L AST (SGOT) 92 U/L ALT (SGPT) 31 U/L 56 U/L LDH 151 U/L 307 U/L CRP 304 mg/L 144 mg/L TSAT 57.93%

45. Test BMU PTH 23.8 pg /ml Ca 5.8 mg/dl Mg 0.7 mg/dl Na 132 mmol/l K 3.8 mmol/l S. Creatinine 1.35 mg/dl Fibrinogen 759 mg/dl D-Dimer 1.35 ug/ml NT proBNP 6056 pg /ml

46. Test BMU ANA Negative ENA profile PCNA+, Ku+ Sputum culture MDR Klebsiella & Candida spp. Gene Xpert Ultra MTB not detected Blood C/S(fan Method) No growth HRCT chest Bilateral pneumonitis with Right sided consolidation

47.  Diagnostic Breakthrough

48. CT Abdomen & Thigh: Abscess within the thigh mass USG-guided Aspiration & Core Biopsy: Pus was sterile (no microbial growth) Sample obtained for histopathology Histopathology Report: Diagnosis:  Dedifferentiated Liposarcoma

49.   Definite Diagnosis Dedifferentiated liposarcoma (left thigh) with secondary soft tissue infection with Pneumonia & Anemic heart failure and HTN, DM, CKD, Hypothyroidism.

50. Feature Our Case (Thigh DDLPS) Vishnoi et al. (Retroperitoneal DDLPS) Presenting Symptoms Fever, fatigue, anemia, weight loss Fever, weakness, anemia, weight loss Lab Findings Anemia, ↑WBC thrombocytosis, ↑ CRP/ESR Anemia, ↑WBC thrombocytosis Diagnostic Pitfall Extensive infectious/autoimmune workup Extensive infectious workup Final Diagnosis Thigh DDLPS Retroperitoneal DDLPS Outcome Inflammation improved post-transfer Symptoms resolved after resection

51. Thank You

52. CBC Parameter 08-09-25 05-09-25 31-08-25 27-08-25 15-08-25 18-07-25 Hb (g/dL) 11.2 6.2 8.7 7.3 7.50 8.1 ESR (mm/1st hr) 44 34 95 100 - 68 WBC (x10⁹/L) 22.0 25.0 26.5 34.0 19.05 22.04 RBC (x10¹²/L) 4.36 2.50 3.13 2.76 3.74 3.10 Platelets (x10⁹/L) 180 500 N/A N/A 477 488 Neutrophils (%) 92 92 87 90 80 82 Lymphocytes (%) 7 5 11 6 10 13 MCV ( fL ) 78.2 84.1 84.7 83 81 RDW-CV (%) 21.9 17.2 17.5 15.7 27.40 25

53. PBF Persistent neutrophilic leukocytosis D imorphic/microcytic anemia, Thrombocytosis Reticulocytosis (3.47%)

54. Renal, Electrolytes Recurrent Hyponatremia : Na⁺ 126–132 mmol/L (persistent) Hypokalemia : K⁺ 2.5–3.3 mmol/L Hypocalcemia : Ca²⁺ 5.6 mg/dL Hypomagnesemia : Mg²⁺ 1.0 mg/dL Elevated Creatinine : 1.3–1.9 mg/dL → Evidence of CKD (confirmed by USG)

55. Urine R/M/E (05-Sep-2025) Urine R/M/E (05-Sep-2025) – Mild proteinuria (2+) with plenty of pus cells and few RBCs suggests active urinary tract inflammation , likely infective in nature (probable lower UTI). Absence of casts or crystals rules out significant tubular or glomerular involvement

56. Biochemistry: Liver Function Test Hyperbilirubinemia : Total bilirubin peaked at 10.8 mg/dL; improved to 2–3 mg/dL Bilirubin Direct: 8.38 → 0.5 mg/dL Bilirubin Indirect: 2.41 → 1.3 Hypoalbuminemia : Low serum albumin with A/G ratio 0.65 Marked ↑ Alkaline Phosphatase (ALP) : 822 U/L → 1,386 U/L (progressive rise) LDH: 211 → 151 Polyclonal Hypergammaglobulinemia : Suggestive of chronic inflammation/liver involvement

57. Immunology Inflammation & Autoimmune CRP: very high (304 → 237 mg/L) S Ferritin: 12784 →4264 ng/L S. Fibrinogen: 759 mg/dl ANA -Negative ENA profile: RPP/PO+, Ku+, AMA-M2+ Coombs Test: Direct positive indirect negative SPEP: Polyclonal hypergammaglobulinemia

58. Infection Infectious disease HBsAg negative ; HCV negative MDR Klebsiella & Candida (sputum) Blood/urine cultures: negative Pus aspirate thigh: no organisms, MTB negative

59. Others ICT for Kala-azar: Negative ICT for Malaria: Negative ICT for Leptospira: Negative Thyroid Function Test Normal Pro BNP 6030 pg /ml

60. Bone Marrow done twice Hypercellular, myeloid hyperplasia, dimorphic erythropoiesis

61. Imaging USG abdomen : Hepatomegaly, CKD kidneys Echo : Concentric LVH, mild MR, EF 65% Chest X-ray : Bilateral inflammatory opacities Upper GI Endoscopy: Normal Full Colonoscopy: Rectal Polyp(Polypectomy done) MRCP: Hepatomegaly and prominent Spleen

62. Imaging… Bone Scan: Normal. Single Solid area in thigh USG thigh : SOL →Vascular Malformation CT Abdomen and thigh : Hepatomegaly ,Mild Splenomegaly, Abscess in Thigh

63. Histopathology Dedifferentiated liposarcoma, FNCLCC grade 2

64. CBC and PBF 29.0525 5.7.25 11.7.25 20.7.25 23.7.25 27.7.25 Hb 8.7 3.8 10.2 6.3 3.5 9.6 ESR 32 140 85 46% 45 TC 15350 18270 31000 32300 26250 N 91% 88% 88% 93% 95% PC 533000 372000 541000 577000 526000 PBF Normocytic normochromic Leukocytosis

65. Other Hematological test Coomb’s test: Direct- Positive Indirect- Negative Reticulocyte count- 3.47% LDH(135-225) : 151( ) 211 (15.7.25) Ferritin- 4160 (25.5.24), 10600 (11.7.25) Protein electrophoresis-Polyclonal hypergammaglobulinemia with marked hypoalbuminemia

66. LFT 15.7.25 24.7.25 27.7.25 Bilirubin Total 10.79 2.79 1.72 Direct 8.38 1.79 Indirect 2.41 0.82 ALT 31 70 ALP 822

67. RFT 11.5.24 4.7.25 11.7.25 22.7.25 27.7.25 Creatinine 2.1 1.5 1.80 1.59 Electrolytes Na 138 119 126 129.8 130.3 K 4.2 5.7 3.6 3.41 3.17 Cl 101 85 87 95.7 95.8 Urea 47.7 Urine RME Pus- 6-10 Albumin-+ Sugar- Yellow

68. RBS 21.2.25 11.7.25 RBS 25.12 28.7 HbA1c 9.2 S. TSH -2.91

69. Lipid profile 21.2.25 TC 116 HDL 38 LDL 52 TG 182

70. Others test ANA-Negative Stool for OBT-Negative S. Ca++ -8.3 Vit D: 19.5 ( Insufficient)

71. Differential Diagnoses   Malaria (especially falciparum) Fever with jaundice and splenomegaly. Secondary haemolysis common. Needs to be ruled out by peripheral smear/rapid antigen test. Mycoplasma pneumonia with hemolysis -Less likely given absence of respiratory focus but remains differential for PUO + haemolysis . Septicemia with hemolysis (e.g., Gram-negative sepsis, mycoplasma pneumonia) Prolonged fever without focus, jaundice, anaemia . Possibility of secondary haemolysis in severe infections.

72. Differential Diagnoses Autoimmune Hemolytic Anemia- Chronic anemia, repeated transfusions, fever, jaundice (hemolytic), pallor, mild splenomegaly Hematologic Malignancy ( Leukaemia /Lymphoma)- Fever, anemia, mild hepatosplenomegaly, generalized symptoms Transfusion- Related Infection/Delayed-Hemolytic Transfusion Reaction- Multiple transfusions, chronic fever, mild jaundice, soft tissue swelling, jaundice, splenomegaly, fever, anemia Left thigh Hemangioma/Sarcoma/Hematoma/Lipoma/Abscess

73. Parameter 2025-09-05 2025-08-31 2025-08-21 2025-07-24 2025-07-16 ALT (SGPT) (U/L) - 17 - - 31 AST (SGOT) (U/L) - 27 - - - ALP (U/L) 1536 210 - - 822 Bilirubin Total (mg/dL) - 1.8 1.78 2.79 10.79 Bilirubin Direct (mg/dL) - 0.5 1.60 1.97 8.38 Bilirubin Indirect (mg/dL) - 1.3 - 0.82 2.41 LDH (U/L) - - - 151 211 Albumin (g/L) - 20 - - - CRP (mg/L) - - 144.14 - -

74. Diagnostic Workup Imaging: USG Abdomen: Hepatomegaly, CKD kidneys Echo: Concentric LVH, mild MR, EF 65% Chest X-ray: Bilateral inflammatory opacities GI Endoscopy: Normal; Colonoscopy: Rectal polyp (removed) MRCP: Hepatomegaly + prominent spleen USG Thigh: SOL → Vascular malformation Contrast MRI thigh → Vascular malformation Bone Scan: Normal except solid thigh lesion Bone Marrow: done twice Hypercellular, myeloid hyperplasia, dimorphic erythropoiesis

75. As the patient’s clinical condition showed no significant improvement, she was transferred to Bangladesh Medical University for further evaluation and definitive work-up. A CT scan of the abdomen and left thigh revealed an abscess within the thigh mass, Prompting USG-guided aspiration and core biopsy. Although aspiration yielded sterile pus with no organisms on culture, the histopathological examination of the biopsy specimen demonstrated a dedifferentiated liposarcoma

76. ----------------------------------

77. According to the statement of the patient she was reasonably well 1 month back. Then she developed fever which is low grade, continued. Highest recorded temperature 101°F, without chills and rigors. Fever was partially relieved by antipyretics. There is no history of evening rise of temperature, drenching night sweats or contact with known TB patients. No recent travelling history to endemic zone.

78. Fever was associated with cough and breathlessness. Cough was initially dry with occasional mucoid expectoration, not blood mixed, no diurnal variation. It was not associated with chest pain.

79. Breathlessness was insidious on onset, gradually progressive. Initially it was associated with moderate to severe exertion but later on it was so severe that she was unable to perform her daily activities. Patient denied any history of orthopnoea or PND, diurnal variation or relation with occupational exposure.

80. With these complaints she visited a registered physicians and after doing some routine investigations she was found anemic with raised inflammatory markers and advised for blood transfusion. 2 units of fresh crossmatched blood was transfused after admission in a private hospital. She also received IV broad spectrum antibiotics and other medications, but condition was not improved.

81. She developed yellow discoloration of her eyes, skin, urine which was progressively increasing. She did not have pale stools, itching, abdominal swelling, pain, nausea or vomiting.

82. For evaluation of anemia and jaundice she consulted with hematologist and hepatologist and advised to be admitted in SZMCH. After getting treatment with IV antibiotic along with other medication her jaundice improved but anemia and fever persists. Over this period she received repeated blood transfusion.

83. For last 4 months, she noticed a swelling behind her left thigh which was initially painless later became mild painful , progressively increasing in size with increased warmth over the area. She denied any history of trauma or discharge. Sonography was advised and reported it as Haemangioma.

84. During this period of her illness she loses 6 kg body weight. There was no history of syncope, palpitation, burning micturition, joint pain, rash, oral ulcer, photosensitivity, nodular swelling in any part of the body, altered conscious level, previous history of jaundice, hematemesis or malena .

85. She was on regular medication for her multimorbidities like DM, HTN, CKD and Hypothyroidism with good compliance.

86. Any Questions???

87. On general examination patient is anxious, ill looking well co- operative, on choice decubitus, of average body built and nutrition. She is severely anemic, mildly icteric, temperature was 101° F, pulse 104 b/mins, BP 140/80 mmHg, respiratory rate 22 breaths/mins, spo2 96% on air.

88. Investigations

89.   Definite Diagnosis Dedifferentiated Liposarcoma of left thigh, complicated by secondary soft tissue infection & HTN & Dm with CKD & Hypothyroidism

90. Any Questions???

91. Provisional Diagnosis Pyrexia of Unknown Origin (PUO) with secondary haemolytic anaemia & Diabetes mellitus & & Hypertension & Hypothyroidism & Chronic kidney disease with Left thigh solid mass Most probably: Leptospirosis Leptospirosis Prolonged fever, jaundice, renal involvement (CKD background), exposure risk through animals. Can cause haemolytic anaemia and hepatic involvement.