Georgian Telemedicine Union (Association)

Patient: 55 years old male

Clinical: The illness began on September 2004 with flu-like symptoms. Soon after, the patient presented with a tumor at the left-upper area of the neck. This was accompanied by pain and increasing of body temperature. The skin at the area of the tumor was dense and hyperemic, palpation was hardly painful. Surgical treatment – dissection was done and anti-inflammatory treatment was given. On October 2004, some conglomerates of lymph nodes of different sizes at both sides of the neck at upper one third were revealed. The low and middle areas of the neck were intact. During the last 3 months, there was an increased enlargement of the tumor formations (especially at the left side). Surgical dissection of tumor formation at left side of neck was done on 25 July, 2005.

Laboratory

Peripheral Blood Counts:

16 September, 2004

22 September, 2004

20 October, 2004

10 February, 2005

Hemoglobin – 137.00 g/L

Erythrocytes – 4.1

Color index – 1.00

Leukocytes – 10.7 x1000/mm3

Stab neutrophils – 11.00%

Mature neutrophils – 48.00%

Eosinophiles – 6.00%

Lymphocytes – 28.00%

Monocytes – 7.00%

Erythrocyte Sedimentation Rate – 13 mm per hour

Hemoglobin – 140.00 g/L

Erythrocytes – 5.3

Color index – 0.8

Leukocytes – 6.5 x1000/mm3

Stab neutrophils – 2.00%

Mature neutrophils – 51.00%

Eosinophiles – 3.00%

Lymphocytes – 31.00%

Monocytes – 10.00%

Erythrocyte Sedimentation Rate – 12 mm per hour

Note: Lymphocytes with wide cytoplasm area were revealed

Hemoglobin – 144.00 g/L

Erythrocytes – 4.0

Color index – 1.0

Leukocytes – 10.0 x1000/mm3

Mature neutrophils – 64.00%

Eosinophiles – 1.00%

Lymphocytes – 20.00%

Monocytes – 15.00%

Erythrocyte Sedimentation Rate – 25 mm per hour

Hemoglobin – 166.00 g/L

Erythrocytes – 4.9

Color index – 1.0

Leukocytes – 3.7 x1000/mm3

Stab neutrophils – 9.00%

Mature neutrophils – 65.00%

Lymphocytes – 19.00%

Monocytes – 6.00%

Erythrocyte Sedimentation Rate – 8 mm per hour

Ultrasound investigation

21 September, 2004

Conglomerates of lymph nodes are revealed at both sides of neck. At right side their size varies in 15-25 mm margins, at left side – in 22-26 mm margins. Adenomatous node (6 mm) is observed in right lobe of thyroid.

29 February, 2005

Liver: Sagital dimensions are not increased. Frontal edge at medioclavicular line doesn’t go out from ribs’ arc. Vertical-oblique size of right lobe is 146 mm. Cranio-caudal size of left lobe is 82 mm. Angles are sharp. Contours - even. Parenchyma echo structure - homogenous. Echogenity – middle. Echo conductivity is kept. Nodular changes are not observed. Vascular picture unchanged. Diameter of portal vein in intrahepatic part – 9.5 mm. Doplerographic flow is hepatopetal, even. Flow maximal speed is 17.8 cm/sec, minimal speed – 16.8 cm/sec, average – 16.9 cm/sec. Volume speed is 1001 ml/min.

Intrahepatic and outhepatic biliary ducts are not dilated. Diameter of common bile duct – 6 mm. Internal space – free.

Gallbladder – despite the objective that investigation is performed on an empty stomach gallbladder is boomerang shaped, it is observed as narrow non echogenous formation. Free bile practically could not be observed in it.

Abdominal aorta – diameter 17 mm. Lower cava – diameter 21 mm. Inner space – free, walls – unchanged.

Pancreas – dimensions: head – 24 mm, body – 14 mm, tail – 22 mm. Contours – even. Echo structure - homogenous. Wirsung’s duct is not dilated.

Spleen – dimensions 104x44 mm, doesn’t go out from ribs’ arc. Echo structure – homogenous. Echogenity – middle. Diameter of spleen vein is 5.5 mm.

Free liquid in abdomen is not observed.

Lymph nodes along with portal vein, spleen vein, paraaortic, paracaval, mesenterial, femoral magistral blood vessels are not enlarged.

At right side of inguinal area two lymph nodes of decreased echogenity with size 8 mm and 8.5 mm are revealed. Cortical layer and central echo complex could not be observed in their inner structure, which is presented as oval structures of decreased echogenity.

At left side of inguinal area one superficial lymph node of analogous echo appearance of 8.5 mm size is observed.

In armpit triangles enlarged lymph nodes are not observed.

At both sides of neck triangle projection conglomerates of lymph nodes are revealed. Their echogenity is decreased; contours are uneven, structure – inhomogeneous. On the background of their echo appearance their infiltration could be suspected. Inner atypical vascularization was not revealed, only strengthened peripheral vascularization was observed.

Conglomerates of lymph nodes are revealed at both sides submaxillary areas are observed too.

1 March, 2005

Prostate – size 27x45x35 mm. Volume – 22.5 cm³. Capsule – intact without deformation. Structure – inhomogeneous, echogenity is increased at both sides of transitional area projection. At projection of urethra prostate part 2 mm sized petrificate is revealed. Focal damage of other type is not observed.

Testicular vesicles: size – 7 mm (right), 7 mm (left). Symmetrical, content homogenous.

Urinary bladder: unchanged form, mucous relief even and simple. Wall thickness – 3 mm.

Residual urea in little amount – 19 ml.

Cytological investigation

22 September, 2004 - Lymphadenitis.

20 October, 2004

Imprints (biopsy of nasopharynx). In smears elements of inflammation, lymphoid infiltration, cells of cylindrical epithelium with signs of proliferation are revealed.

Biopsy of left neck lymph node – elements of lymph node with dystrophic changes, huge amount of macrophagial and histiocytic elements appeared as interlacements. Epitheloid cells are observed among them. Separately placed small sized groups of epitheloid cells are observed too.

Biopsy of right neck lymph node – elements of purulent inflammation.

8 November, 2004

Cytologic investigation of subcutaneous formation at left side of neck – elements of lymph are revealed (formation disappeared after biopsy).

Cytologic investigation of subcutaneous formation at right side of neck – elements of granulematous epitheloid cellular lymphadenitis.

Endoscopic investigation (20 October, 2005)

Nasal ducts are free at both sides. Mucous at nasopharynx arch – hyperemic, hypertrophic, hyperplastic. Mucous of larynx and pharynx - moderately hyperemic. In front of right vocal chord, near commissure, angiofibromatous polyp (size 0.5-0.6 cm) with corneal surface. Movement of vocal chords - active. Polyposis of right vocal chord.

Tomography

20 October, 2004

Mediastenum without pathologic changes.

9 February, 2005

Lungs of usual pneumatization, lung picture is unchanged. Foci of pathologic density and additional formations in lung are not observed. Roots are structural, not enlarged.

Pleural cavities – free.

Mediastenum - two dense bifurcated lymph nodes (diameter up to 9 mm) are observed.

Heart and aorta – normal.

Liver – of normal size, homogenous structure, normal density without additional formations and foci of pathologic density. Contours are obvious and even.

Pancreas: size – normal (head – 23 mm, body – 23 mm, tail – 25 mm), structure – homogenous, density – usual, without additional formations and foci of pathologic density, contours – obvious and even.

Spleen: size – normal, structure – homogenous, density – usual, without additional formations and foci of pathologic density, contours - obvious and even.

Kidney: position – normal, form and size – usual, without additional formations.

Frontal sinuses: in left frontal sinus local hypertrophy of mucous up to 3 mm at lower-medial wall is revealed; main, upper maxillary, right frontal sinuses and cells of ethmoid labyrinth of sufficient pneumatization, without additional formations.

Bone-destruction changes are not revealed.
Cavity of orbits without additional formations, retro-bulbar cellular tissue is not changed.

Histologic investigation

9 February, 2005 - Follicular adenoma

21 February, 2005 – Moderate hyperplasia of lymphoid tissue.

25 March, 2005 - Flat cellular non squamous carcinoma of low differentiation.

Biochemical investigation (22 September, 2004)

Lactatdehydrogenase – 230 U/L (norm – 225-450 U/L)

Serological evaluation

TB – IgG positive, IgM positive, IgA positive (1 October, 2004)

12 October, 2004

Anti-microbial, anti-staphylococcal immunoglobulins - less than 1:10 (norm up to 1:100)

Immunoglobulins against staphylococcal a-toxin – 1:10 (norm up to 1:20)

Maintenance of a-toxin in blood – is not detected

28 October, 2004

Micro calorimetric investigation of serum – Systemic changes characteristic for tumor were not revealed.

28 April, 2005

TOXO – IgM negative, IgG negative

Roentgen investigation (1 October, 2004)

Pulmo et Cor – without pahology

Comments: Please, write back with your opinion and suggestions about further treatment strategy of this case to Eka Kldiashvili, Ph.D. kldiashvili@georgia.telepathology.org, Georgian Telemedicine Union (Association), Tbilisi, Georgia.

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