ACP Poster Presentation--Winning Clinical vignette Student 2016

Although you can see the conclusion we finally reached, I would like to present this case to you as it came to us, which is something of a medical mystery. The patient was a 44-year-old man with refractory AIDS who was diligently following cardiac therapy. who presented to the UC Davis emergency department with several days of nausea, vomiting, diarrhea, and recurrent night fever on examination, was hypotensive, tachycardic, and febrile, and is therefore admitted for treatment for possible sepsis. He had not attended the hospital twice in the previous year with similar symptoms, so when he came to us he was already being treated for suspected Mycobacterium avium complex or Mac in his first week he continued to have fever and diarrhea a CT scan showed scant lymphadenopathy with notes too small for a biopsy. were elevated in a cholestatic pattern and this was ultimately attributed to the hepatic toxic effect of his emaki.

Ultimately this was discontinued. He had recurrent pancytopenia during the first week requiring multiple blood transfusions and this made us think about the costs of marrow suppression, perhaps a different infection or malignancy in the second week, he continued to do poorly despite the antibiotic therapy, he continued to have fever and a repeat CT scan showed rapidly growing splenic calcifications which can be seen here because he lived in Pennsylvania we thought maybe disseminated histoplasmosis and I gave him a single dose of amphotericin B at the same time we got a biopsy of bone marrow and this showed KC Adan granulomas and large nucleated cells of atypical appearance that once stained turned out to be Reid Sternberg cells and this gave us a diagnosis of Hodgkin lymphoma.

Additional testing gave us elevated levels of soluble IL-2 and ferritin which, in addition to his fevers, hepatosplenomegaly, and pancytopenia, gave us a second diagnosis of hemophagocytic lymphohistiocytosis, or HL. The patient was started on solu-medrol and vincristine for Hodgkin lymphoma and etoposide for HL. h and showed initial improvement with this regimen, however, he began to decompensate, had to be taken to the ICU, and eventually succumbed to his illness. Human phagocytic lymphohistiocytosis or hhl is a rare and aggressive condition caused by excessive activation of the immune system; although it has rarely been found. In the literature it is considered to be both a potential trigger and an early

clinical

manifestation of Hodgkin lymphoma, which is a malignant disease associated with AIDS.

What we learned from this case is that HL H is difficult to diagnose, it lacks confirmatory tests and the symptoms are non-specific, so it is difficult to initially suspect it in this patient, furthermore, he did not have Hema Faga in his biopsy. bone marrow, but this is neither a necessary nor sufficient criterion for the diagnosis. Additionally, some articles are beginning to show that Hema Faker cytosis may be more easily noticeable in series versus individuals. bone marrow biopsy Another special thing about this case was the diagnosis of Hodgkin's lymphoma and the bone marrow biopsy this is unusual, generally the constitutional symptoms of cervical lymphadenopathy are seen, but in him his lymphatic adenopathy was very scarce and the additional feature of diarrhea made us think about more infectious causes, in summary, hemophagocytic lymphohistiocytosis or hHL with Hodgkin lymphoma can be seen in our AIDS patients and therefore should be considered in our immunocompromised patients who present with recurrent fever , hepatosplenomegaly and pancytopenia.