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Case presented on 11th June, 2013 by Dr. Abu Jar Gaffar (MD Endocrinology Final part student) in the Department of Endocrinology, BSMMU
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A middle aged man with severe weight loss &
increasing breathlessness
Dr . ABU JAR GAFFAR MD Final Part student Department of Endocrinology
BSMMU
Patient Profile
• Mr. X• 51 year• Ex smoker• farmer • D/A : 01/06/13
Presenting Complaints
•Cough & shortness of breath – 1 ½ yrs
•Swelling in front of the neck – 1 ½ yrs
•Swelling of both legs – 1 month
History of presenting complaints
Shortness of breath
Start 1 ½ yrs back but increased for last 1 month
Exertional
Awakes from sleep at night
associated with cough occassionally productive,
scanty, whitish with no haemoptysis
no chest pain & having no seasonal variation
History of presenting complaints•Swelling of both legs
progressive reduced urine volume associated with SOB & cough no yellowish urine or sclera or
haematuria
History of presenting complaints•No H/O fever
•But significant weight loss of about 20 kg in last 1 and ½ years.
History of presenting complaints• Diagnosed as a case of Graves thyrotoxicosis
with heart failure on December 2011 on basis of Weight loss heat intolerance increasing bowel habit ( no blood,
mucous, tenesmus, normal in color & amount) painless diffuse neck swelling
SOB, tender hepatomegaly, bilateral leg edema &
Positive biochemical findings
•He was prescribed with carbimazole, captopril, diuretics & was improving gradually.
•But he was on irregular follow up & stopped all medications for last 3 months & subsequently getting worse day by day
Other history• H/O sudden severe chest pain on 2006 , got
admitted in NIDCH, diagnosed as primary spontaneous pneumothorax ( lt), improved with tube thoracostomy
• No H/O TB or contact with TB patients.
• Ex smoker - 20 pack year - Cessation of smoking for last 1
yr due to his illness - No h/o taking inhaler
No one in his family suffering from same type of illness
Low socioeconomic
Physical examination
General Examination• Anxious, cachectic• Mildly anaemic non icteric• Generalized lymphadenopathy involving lt anterior
cervical, Both supraclavicular & medial group of axillary - largest in left axilla (3X2 cm)
- non tender, firm, discrete, mobile. No discharging sinus
• Bil pitting leg edema
General Examination
• JVP : Raised
• Hands : warm, not sweaty, Fine tremor +
• Pulse : 88 bpm
• BP : 120/65 mm of HG
• RR : 24/min
• Temp : Normal
• Thyroid :
Enlarged, diffuse
soft, non tender, mobile
no retrosternal extension
thyroid bruit - present
Systemic examination▫ Respiratory system :
▫ Barrel shaped chest
▫ Breath sound is vesicular with prolonged expiration
▫ Bilateral basal crackles
▫ No evidence of Pleural effusion
▫ Abdomen :
• Liver is palpable 7 cm from right costal margin
along the right midclavicular line, firm, non-tender, smooth surface, regular margin, upper border in rt 6th intercostal space liver span 14 cm
• No Splenomegaly & ascites
Systemic examination▫Cardiovascular system
▫ Apex beat shifted in lt 6th intercostal space, 12 cm from midline, no gallop rhythm, no murmur
▫Nervous system
▫ normal
Differential diagnosis
• Graves thyrotoxicosis with COPD with Heart failure with disseminated TB
• Graves thyrotoxicosis with COPD with Heart
failure with lymphoma
Investigations
CBCDate Hb TC DC ESR
31/01/12 10.5 gm/dl 65
•30.05.13
FT4 7.15 ng/dl (0.8 – 1.5 ng/dl)
TSH 0.004 uIU/ml (0.35-5.8 uIU/ml)
•Chest Xray P/A ( 04.06.13):
Inhomogenous opacity with fibrotic band shadows noted in upper & mid zone of Rt lung field, calcification is in upper zone of rt lung suggestive of sequlae of (rt) pul TB
Rt sided pleural reaction
03.06.13
S. Albumin 30 gm/ltS. Creatinine 0.7 mg/dlS. Na 151, K 3.5, Cl 107, TCO2 25 mmol/L
•Reports awaiting
CBC
Tuberculin test
ECG, Echocardiogram
Spirometry
USG of W/A
Disseminated TB:
Points in favour Points against :
Wt loss
Generalized
lymphadenopathy
Radiographic change
hepatomagaly
Weight loss & lymphadenopathy may be due to Graves disease
No fever
Lymh nodes are not matted
No ascites
No H/O contact with TB patients
LymphomaPoints in favour Points against :
Severe weight loss
Generalized Lymphadenopathy
Lymphnodes are not rubbery
No spenomegaly , ascites
Problems
•Diagnostic dilemma
•Is it necessary to perform any more further investigations to reach the diagnosis?
•What will be the further management?