Lymphoma Case: I have fever, itching, and a mass in my neck!

Hey guys, this is Medicos is Perfection Analysts today, and let's discuss a medical case. You have a patient with fever, itching, and annek mess. Let's get started.

But before we get started, let me remind you that I have a playlist on my channel named Medicos Vignettes. You'll find lots of medical cases in it. Now, let's get started.

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Today, we not only have one question but 10 questions. After I read every one of them, please pause the video and try to answer, and let me know below in the comment section how many questions did you answer correctly. Don't cheat.

22-year-old Caucasian male comes in complaining of fever, night sweats, and let's add some itching and a mass in the right side of his neck. On physical exam, you find painless enlarged cervical lymph nodes. You send some labs: hemoglobin 9.2, MCV 90, Matic red 30, serum LDH was off-the-charts, lymphocytes of 520 per microliter.

Question: What was the next step? Call the legal guardian, start chemotherapy, order iron studies, radiation to the lymph nodes, or percutaneous core needle biopsy?

Now, pause the video.

Okay, call the guardian? Nope. Start chemotherapy before diagnosing? Nope. Order iron studies? Not radiate the lymph nodes. We should diagnose it first. So, the correct answer is percutaneous core needle biopsy. And by the way, this is different from fine needle aspiration. There are two types of biopsies that are done using a needle. First one is the core needle biopsy, and the second one is the fine needle aspiration. These are different.

We continue with the same patient. So, the pathologist reported seeing these cells under the microscope while examining the lymph node biopsy and also reported that it was rubbery in consistency. I told you before that experienced pathologists use consistency to comment on the section.

So, what's the most likely diagnosis? Diffuse large b-cell lymphoma, Burkitt's lymphoma, Hodgkin's lymphoma, mantle cell lymphoma, or infectious mononucleosis?

The third question: What should you do next? Send the patient home, watch and wait, start chemo immediately, or CT scan?

Pause.

So, the second question: What's the most likely diagnosis? You have these owl-eye appearing cells. They have two nuclei, and each nucleus has a nucleolus that is eosinophilic. Also, we have a rubbery lymph node. So, the diagnosis here is C, Hodgkin's lymphoma.

What should you do next? Send the patient home? This is an idiot. Watch and wait? Observation, that's an idiot on steroids. Start chemo immediately? That's a doctor who is studying using Kaplan. I'm sorry, this is a joke. How can you use chemo for staging? So, the answer is D, CT scan of the neck, chest, abdomen, pelvis for the purpose of staging, because staging determines treatment.

Fourth question: Which of the following subtypes of that disease has the best prognosis? Nodular sclerosing, lymphocyte depleted, or mixed cellularity?

Pause.

And the answer is, of course, nodular sclerosing has the best prognosis. And I've told you that nodular sclerosis is commoner in females. Remember roses, flowers for female. Then you order CT scan for staging and a PET scan. You find the disease involving cervical lymph nodes and anterior mediastinal lymph nodes that are bulky, as well as splenomegaly. Using the Ann Arbor classification, which stage is this disease? Stage 1, stage 2, stage 3A, stage 3B, or stage 4?

Then suppose that the disease involved the liver and the bone marrow. Just suppose. Which stage is the disease now?

Pause.

So, the answer here is, we have a patient with lymph nodes that are more than one cervical, anterior mediastinum, splenomegaly, and they are on both sides of the diaphragm. So, this is stage 3. Now, is it 3A or 3B? The question is, does the patient have constitutional symptoms such as fever, itching, weight loss, drenching sweats? And the answer is yes. So, the stage is 3B because we have constitutional symptoms.

Cool. Suppose that disease involved the liver and the bone marrow. Now we are talking about extralymphatic tissue, and this is stage 4.

Which of the following factors carries a poor prognosis? Age of 22 years, female gender, male gender, serum albumin greater than 40?

The answer is male gender carries a poor prognosis. Female gender, very good prognosis. Age of 22 doesn't matter, but age greater than 45 carries a poor prognosis. Serum albumin less than 40 also carries a poor prognosis.

Let's continue. The staging was confirmed as stage 3B. What's the best treatment option? Radiation only, CHOP regimen, chemotherapy only, ABVD regimen, chemotherapy only, ABVD plus radiation, or Brentuximab vedotin?

Please pause.

And here the answer is ABVD plus radiation. Adriamycin, bleomycin, vinblastine, dacarbazine plus radiation. Why? Because the patient is stage 3B. Radiation only, maybe for stage 1, maybe stage 2, but stage 3B, you need chemotherapy for sure. How about Brentuximab vedotin? No, Brentuximab vedotin is only for diseases that relapsed after transplant or multiple lines of chemo. How about chemo only? No, you need radiation because you have bulky lymph nodes in the anterior mediastinum. How about CHOP regimen? CHOP is for non-Burkitt's lymphoma. ABVD is for Hodgkin's lymphoma.

So, what's next? The ABVD regimen can have side effects. Which of the following side effects match with the corresponding drugs? So, here is bleomycin and here is Adriamycin.

A. Does bleomycin cause England brain cancer and Adriamycin pancreatitis?

B. Bleomycin causing cough and dyspnea while Adriamycin causing cardiomyopathy?

C. Early coronary disease with bleomycin, pancreatitis with Adriamycin?

D. Early coronary disease with bleomycin, cough and dyspnea with Adriamycin?

And the correct answer is B. Cough, dyspnea with bleomycin because bleomycin causes interstitial pulmonary fibrosis. How about Adriamycin? It causes cardiotoxicity such as cardiomyopathy. So, B is the answer.

Last question. Congratulations, the patient was cured. Woohoo! Good job, doctor. But oh my, I hate this. But 10 years later, he complains of fatigue, weight gain, hair loss, and constipation. Which test should you order? EKG, pulmonary function tests, thyroid panel, or liver function test?

And the answer is thyroid panel. These are symptoms of hypothyroidism. Hypothyroidism is a common complication of radiation used to treat Hodgkin's lymphoma. So, he treated this patient with radiation 10 years ago. Now he presents with hypothyroidism. Get the thyroid panel to confirm.

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