Case Virchows

7/27/2019 Case Virchows

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BAB I

CASE PRESENTATION

I. identity

Name: Mrs. S

Age: 27 years

Gender: Female

Occupation: Housewife

Address: Bukung

II. Anamnesis (Alloanamnesis)

Main complaints: a lump in the neck

Additional complaints: fever

History Disease Now:

Patient was taken to hospital Arjawinangung with a complaint of a lump in the

neck since 1 month ago. The patient also had a fever since 5 days ago. Initially

a small lump gradually enlarged.

Past history of disease:

The patient had never had a disease like this before. patient also denies having

diabetes mellitus and hypertension.

Family history of disease:

Patients admitted in my family no one has ever had the same disease.

III. physical examination

Generalist Status

General Condition: Moderate Pain

Awareness: compost mentis

Vital Signs: BP: 120/80 mmHg

N: 92 x / min

S: 37.8 C


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R: 24 x / min

Head: Normocephal

Eyes: Conjunctiva anemis - / -

Sclera jaundice - / -

Pupillary reflex - / -

Neck: The thyroid was not palpable enlarged

KGB: palpable enlarged

thoracic:

I cast: iktus cordis is not visible

P: iktus cordis palpable on ICS V line midclavikula

P: cardiac borders easily assessed

A: BJ regular I-II, murmurs (-), gallop (-)

Pulmo I: symmetrical piston movement in a static state and dynamic

P: vocal fremitus at the right and left hemithorax

P: resonant to both lung field

A: Vesicular, rhonki - / -, wheezing - / -

Abdomen I: convex, symmetric, surgical wound (+)

A: Bowel (+) normal

P: Timpani whole abdominal field

P: soft, tenderness (+), liver palpable 8 cm,

Left Right Superior Extremity: edema (-), warm akral

Right inferior Left: edema (-), warm akral

Localist status:

Lump left neck measuring 5 cm, rubbery, mobile.

Examination Support

Laboratorium

LAB RESULT FLAGS UNIT NORMAL

WBC 8.5 10^3/ 4.0-12.0

LYM 2.8 10^3/ 1.0-5.0


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MON 1.5 H 10^3/ 0.1-1.0

GRANUL 4.0 10^3/ 2.0-8.0

LYM % 36,8 % 25.0-50.0

MON% 17,0 H % 2.0-10.0

GRANUL% 46.2 L % 50.0-80.0

RBC 4.58 10^6/ 4.0-6.20

HGB 12.5 g/dl 11.0-17.0

HCT 39.5 % 35.0-55.0

MCV 86.2 80.0-100.0

MCH 27.3 Pg 26.0-34.0

MCHC 31.6 g/dl 31.0-35.0

RDW 12.6 % 10.0-16.0

PLT 290 10^3/ 150.0-400.0

MPV 8.7 7.0-11.0

PCT 0.252 % 0.200-0.50

POW 14.1 % 10.0-18.0

KGDS : 78 mg/dL

LAB RESULT FLAGS Method NORMAL

Hematologi (darah

rutin)

Waktu perdarahan 2 1-3 menit

Waktu pembekuan 4 2-6 menit

IV. differential diagnosis

1. Hodgin's Lymphoma

2. Virchow's nodule


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V. working diagnosis

Virchow's nodule

VI. management

Medical:

RL infusion of 20 drops per minute

Cefotaxime 2x1 amp

Ketorolac 2x1 amp

debridement therapy: Wound toilet

VII. prognosis

Ad Vitam: ad bonam

Ad Functionam: ad bonam


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BAB II

A. DEFINITION

Nodule was Virchow's lymph node contained in the left supraclavicular fossa (the

area located above the left clavicula).If found an enlarged nodule with hard

consistency (Troiser's sign) is indicating the presence of a malignancy in the

abdominal area, especially gastric cancer, which metastasize to limfogen.

B. HISTORY

Nodules Virchow's immortalized his name is Rudolf Virchow as the founder, a

German pathologist, who first described the relationship with the enlargement of the

gland malignancy in the stomach in 1848. Expert pathological France, Charles Emile

Troiser, in 1889 suggested that the malignancy in the abdominal area can also

metastasize to lymph.

C. Anatomy and histology

Lymph nodes are round-shaped organ with a small size as an immune system are

widely distributed throughout the body and linked by lymphatic vessels. Lymph node

cells stored on B lymphocytes, T, and other immune cells. Lymph-node serves as a

filter. These nodes also have clinical significance, can become inflamed or enlarged in

various conditions (from infection to malignancy). Based on clinical signs, can be

determined the degree of malignancy can be determined so that the therapeutic action

and disease prognosis.

Lymph node is surrounded by a fibrous capsule and in the lymph node the fibrous


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capsule extends to form trabeculae.Substance of the lymph nodes are divided into

outer cortex and inner medulla is surrounded by a constituent except the hilum area,

where the medulla associated with the surface.

Thin reticular fibers, elastin and reticular fibers form a strong fabric known as

interlacing reticular in the node, with in which there are white blood cells, particularly

lymphocytes, in the form of solid follicles in the cortex. Elsewhere there are

sometimes only white blood cells only. Not only strengthen the fabric of the reticular

structure but also provides a surface for adhesion of dendritic cells, macrophages and

lymphocytes.Interwoven enables the exchange of material transported through the

blood-venule endothelial venules and provide growth factors and regulators are

required for the activation and maturation of immune cells. The amount and

composition of the follicles and change in particular when dealing with the antigen

and form a germinal center.

Lymph sinus is a channel with a crease in it there is lymph node by the endothelial

cells with fibroblast reticular cells and allows the lymphatic flow, embut through

it. Subcapsular sinus sinuses are located inside the capsule and endoteliumnya

continues into afferent lymphatic vessels.This sinus is also continuing with similar

sinuses flanking the trabeculae to the cortex in it (cortical sinuses). Cortical sinuses

flanking the trabeculae drain into the sinuses of the medulla, where the flow of

lymphatic flow to efferent lymphatic vessels.

Multiple afferent lymphatic vessels branched and extends inside the capsule bring

lymph to the lymph nodes. Lymph node subcapsular sinus is entered. The innermost

layer of the afferent lymphatic vessels continued to frown cells of lymphatic

sinuses. Lymph is slowly filtered through the substance of the lymph nodes and

eventually reach the medulla. On his way to see the sap beninng lymphocytes and

their activation may be initiated as part of the adaptive immune response. Concave

side of the lymph node is called the hilum. Efferent hilum by binding tightly

interwoven reticulum and carry lymph out of the lymph nodes.

CortexIn the cortex, the subcapsular sinus flows into trabecular sinuses and lymph

flow to the sinuses of the medulla.The outer cortex is composed mainly by B cells

arranged as follicles, which can form the germinal centers as against the antigen, the

deeper cortex mainly consist of T cells This zone is known as subcortical zone where


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T cells primarily interact with dendritic cells and in which the reticular densely

interwoven.

MedullaThere are two structures in the medulla name:o Corda medulla is corda and

lymphatic tissues including plasma cells, macrophages and B cellso medulla sinuses

(or sinusoids) are vessel space that separates the medulla corda. Lymph flow to the

medulla of the sinus cortical sinus and into the efferent lymphatic vessels. Sinus

medulla contains histiiosit (Immobile macrophages) and reticular cells.

Lymphatic flowLymph flow to the lymph nodes via afferent lymphatic vessels and

lymph flow into the space under the capsule called the subcapsular sinus.Subcapsular

sinus flow into trabecular sinuses and finally into a sinus medulla.Sinus cavity was

crossed pseudopoda macrophages, which contribute to memperangkap foreign

particles and the filter lymphatic. Sinuses of the medulla met in spleen and left hilum

and lymph nodes through efferent lymphatic vessels and then flow into the subclavian

vein, postkapiler venules, cross the wall through the process of diapedesis. B cells

migrate to the nodular cortex and medulla. T cells migrate into the inner cortex

(parakorteks).

When lymphocytes recognize the antigen, B cells are activated and migrate togerminal centers. When the antibody produced by plasma cells are formed, they

migrate to the spinal cord.Stimulation of lymphocytes by antigen migration process is

accelerated by 10 times faster than normal, resulting in a characteristic swelling of the

lymph nodes. Spleen and tonsils adal lymphoid organ that has the same function as

lymph nodes, spleen of blood through the filter more than through the lymph nodes.

Distribution Lymph nodes in head and neck:

cervical lymph node anterior cervical: glands here, either superficial or deep, back in

the muscle strenocleidomastoideus. They drain the contents into the throat and

posterior pharynx, tonsils and thyroid gland. Posterior cervical: These glands

extending to the posterior sternokleidomastoideus but in front of the trapezius, from

the highest part of the mastoid temporal bone to the clavicle. The gland is enlarged

when there is infection of the upper airway.

Tonsil or submandibular: These glands are located below the mandibular angle,along the bottom of the chin. They flow into the tonsils and pharyngeal region,


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including the basic structure of the mouth and the maxillary anterior and molar 1 and

2. They also flow to the mandibular teeth except the incisors.

Retrofaring: limf drainage from mole palate and the third molar.

Sub-mental: These glands are located just below the chin. They flow into the

middle incisors, floor of the mouth and base of the tongue.

supraclavicular lymph nodes: these glands run along the clavicle, where the lateral

joins the sternum. They flow into the thoracic cavity and abdomen.Virchow's nodule

in the supraclavicular lymphatic glands are receiving from all over the body

limfatiknya flow through the ductus thorasikus and is a favorite place for metastatic

malignancies

Thoracic lymphatic glands

Lymphatic glands in the lungs: limf drained from the lung tissue through the lymph

nodes subsegmental, segmental, lobar and inter lobar lymph nodes leading

to hillus, which are located around the hilum. The flow of lymphatic flow to the


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mediastinal lymph nodes. Mediastinal lymph nodes: they consist of a several lymph

node groups limfatik, especially along the trachea, along the esophagus

and between the lungs and diaphragm. In the mediastinal lymph node glands from

lymphatic ducts which drain into the subclavian vein limf the left. Mediastinal lymph

nodes along the esophagus programs so closely connected in the abdominal lymph

nodes along the esophagus and stomach. This fact facilitates the spread

of tumors via the lymphatic pathways in cases of malignancy in the stomach and part

of the esophagus. Through the mediastinum, the primary lymphatic drainage through

the abdominal organs through the duct thorasikus, where the main flow of the

abdomen is limf into the gland.

D. CLINICAL REASONING

Malignancy, malignancy of the internal organs can reach an advanced stage before

giving symptoms. For example, gastric cancer can be asymptomatic but


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already metastasize. Point that it can be seen where the tumor is already

metastatic at the left supraclavicular lymph nodes. Lymphatic nodules

supraklavkular left is the classic Virchow nodules because nodules are located on the

left side of the neck where almost allthe body's lymphatic drainage (from

thorasikus duct) into the left sub clavian vein kesirkulasi through. Metastasis

thorasikus clog ducts and cause regurgitation into the round nodules to

nodules Virchow example. Another concept is that one of the nodules

supraclavicular nodes correspond to the end of the journey along the duct and

therefore have an enlarged thorasikus.

E. DIAGNOSIS

Differential diagnosis of nodular enlargement of Virchow was lymphoma,

malignant intra - abdominal malignancies, breast cancer and infections (the arm).

Similarly, the enlargement of the lymphatic nodes tend to refer to the right

supraclavicular thoracic malignanciessuch as lung cancer and esophagealcancers such

as Hodgkin's lymphoma.

F.MANEGEMENT

Obtained when the size of lymph nodes>1 cm then it is said to be abnormal, and a

biopsy should be performed to determine the type of disorder. Lymph node biopsy

in two ways: by simply taking a portion ofa lymph node or lifting as well.

Operation Technics

Made an incision in the skin below the surface of an enlarged lymph node and

surrounding tissue is carefully dissected away from the node. Should pay attention

to the surrounding nerve tissue, especially in the area around the neck. To

facilitate removal of the node, the association made with yarn that is attached to the

center of the node, that node can be removed.


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REFERENCES

1. Virchow R. "Zur Diagnose der Krebse in Unterleibe". Med. Reform.

1848; 45: 248

2. Troisier CE. "L'adnopathie sus-claviculaire dans les cancers de

l'abdomen". Arch. Gen. de Med. 1889; 1: 129138 and 297309

3. Libman H. Generalized lyphadenopathy. J Gen Intern Med 1987;2:48-

58

4. Morlan B. Lymphadenopathy. Arch Dis Child 1995; 73: 476-9

5. Pangalis GA, Vassilakopoulus TP, Boussiotis VA, Fessas P. Clinical

approach to lymphadenopathy. Semin Oncol 1993; 20; 570-82

6. Mizutani M, Nawata S, Hirai I, Murakami G, Kimura W. Anat Sci Int

2005; 80(4): 1938

7. http://www.dokterbedahherryyudha.com/2012/03/diagnosis-and-management-

virchows-node.html

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Case Virchows