Extensive lymphadenopathy in the submandibular region as well as anterior and posterior cervical triangle with the largest node measuring 2.7 x 2.5 cm in the right anterior triangle. Extensive lymphadenopathy was also seen in the mediastinal, pre-cardiac, hilar and periaortic areas. Lymphadenopathy at the right hilum compressed the bronchus intermedius.
Extensive consolidation was seen involving the right middle and lower lobes containing areas of low attenuation in keeping with a drowned lung. Multiple small nodules were seen in both the left and right lungs with interstitial markings seen more prominently on the right side of the chest which may be due to lymphatic obstruction.
CT (images not shown):
Liver and spleen showed enlargement with a small stone in the pelvis of the right kidney but otherwise normal kidneys. Pancreas, adrenals, and bladder were normal. Extensive lymphadenopathy was seen in the abdomen, celiac, para-aortic, and retroperitoneal regions.
moderate gram positive cocci
heavy growth of yeast
few gram negative bacilli
usual flora heavy growth
Amplified Mycobacterium Tuberculosis Direct (AMTD) negative, AFB negative, TB negative
fluid from a pleural tap:
Atypical cells present, cloudy
1400 x 106 WBC, 250 x 106 RBC
poly 1%, lymph 37%, mono 3%, macro 2%, blast 56%
mitotic figures present
morphology, immunophenotype & molecular testing c/w involvement of the pleural fluid by lymphoma cells of B-cell origin
All cultures including bacterial, viral, fungal, & TB were negative
lymph node biopsy from right anterior cervical chain:
sections of the core biopsy show effacement of normal architecture by atypical population of lymphoid cells
consistent with Burkitt-like B cell lymphoma; HIV and EBV related changes
All cultures negative including bacterial, viral, fungal & TB were negative
PPD 0 mm (single current only)
Bone marrow aspirate + biopsy - morphologically negative for lymphoma
Echocardiogram- good systolic function
HHV-7 on serology
EBV >1000/1 000 000 PMN cells by PCR
HIV 1 & 2 Ab positive on EIA
SOMETHING IS STILL PUZZLING:
In returning to speak to the family about the diagnosis more information about the family structure was revealed. We knew that SS's father had died but his mother was living. It turns out that SS's mother is actually his maternal aunt. His biological mother had died prior to the family leaving Zimbabwe of an illness that was likely related to HIV but she was never tested. The father had also had more concerns than heart problems and was also likely HIV positive but had never been tested. Because of the stigma attached with a diagnosis of HIV in their country, the family was reluctant to share this additional information. As a result of entering Canada to seek refugee status, the routine immigration health screening was not completed for the family. It is impossible to prove, but our hypothesis is that SS had acquired HIV either perinatally or antenatally from his mother rather than at the time of his surgery. After his parents' deaths, he was fortunate to have relatives to care for him as many children are left orphaned by HIV. Thus, both biologically and socially, family matters.