ANSWER
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.
Abdominal
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.
Sputum cultures:
–
Serratia
liquifaciens
–
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
Pleural
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
Cervical
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
Other
investigations:
–
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.
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