4/17/2024 0 Comments Shotty lymph nodes hivThe largest one measured 1.9 cm in transverse diameter, 0.8 cm in anteroposterior diameter and 2.2 cm in craniocaudal diameter in the right upper posterior triangle region ( Figure 1). His neck ultrasound revealed prominent and enlarged lymph nodes in bilateral cervical regions. Urine examination did not suggest proteinuria or hematuria. The immunoglobulin profile showed hypergammaglobulinaemia at 20.8 g/L (reference internal 5.95–13.1 g/L). Serum complement 4 was mildly depressed at 0.11 g/L (reference range 0.13–0.38 g/L), while complement 3 was normal. Anti-liver-kidney-microsomal (LKM) antibody was not detected. There was the presence of anti-cardiolipin at 15.3 GPL-U/ml (reference <13.3 GPL-U/ml), lupus coagulant and rheumatoid factor. Anti-Smith (Sm), anti-Ro, anti-La, anti-Scl-70 and anti-Jo-1 were not detected. The screening of autoantibodies against extractable nuclear antigens (ENA) showed the presence of anti-ribonucleoprotein/Smith (RNP/Sm). Anti-double-stranded DNA (dsDNA) was mildly elevated at 69 IU/ml (reference ≤50 IU/ml). Antinuclear antibodies (ANA) were present at 1:640 with a speckled and cytoplasmic pattern. Serologies for atypical organisms were negative, including Salmonella typhi, Bartonella henselae, Brucella abortus and melitensis, and Toxoplasma gondii. Bacterial cultures from peripheral blood, bone marrow, urine, stool and throat yielded no growth. Viral markers including hepatitis A, B and C, Epstein-Barr virus (EBV), cytomegalovirus (CMV), human immunodeficiency virus (HIV), dengue virus, Japanese E encephalitis virus (JEV) were negative. They peaked on day 12 of admission with aspartate transaminase (AST), alanine aminotransferase (ALT), gamma-glutamyl transferase (GGT) and alkaline phosphatase (ALP) at 424 IU/L (reference <42 IU/L), 307 IU/L (reference <51 IU/L), 105 IU/L (reference <42 IU/L) and 272 IU/L (reference interval 74–290 IU/L) respectively, suggestive of predominantly hepatocellular pattern of liver injury. Liver enzymes were normal initially but started to rise on day 8 of admission. Globulin was 47 g/L (reference range 24–37 g/L). Albumin was 32 g/L (reference interval 37–47 g/L). There was a reversal of the albumin to globulin ratio. Triglyceride was normal at 1.3 mmol/L (reference <1.7 mmol/L). Ferritin was 1,166 pmol/L (reference interval 32–342 pmol/L). Lactate dehydrogenase (LDH) was 358 IU/L (reference interval 118–221 IU/L). Erythrocyte sedimentation ratio (ESR) was 76 mm/h (reference <17 mm/h). C-reactive protein (CRP) was 17 mg/L (reference <5 mg/L). The peripheral blood smear showed hypochromia and microcytosis without abnormal blasts. His blood tests showed microcytic anaemia (hemoglobin 9.6 g/dl) due to iron deficiency, leukopenia (3.4 × 10 9/L), lymphopenia (0.8 × 10 9/L) and normal platelet count of 202 × 10 9/L ( Table 1). The rest of the systemic examination was normal. Shotty lymph nodes were noted in the groins bilaterally. Enlarged lymph nodes were also present in the left cervical region but to a lesser extent. The nodes were firm and non-tender without overlying skin changes. Upon physical examination, a chain of enlarged lymph nodes measuring 2.5 cm was noted in the right upper cervical region. He had no family history of autoimmune diseases. He had a painless swelling on the right side of his neck which progressively increased in size. One year later, he presented with a prolonged remittent and intermittent fever of more than three weeks. He was also incidentally found to have Hashimoto thyroiditis with the presence of anti-thyroglobulin and anti-thyroid peroxidase antibodies. He was diagnosed with type 1 diabetes with ketoacidosis. His blood tests showed high glucose (26.7 mmol/L), beta-hydroxybutyrate (3.59 mmol/L), metabolic acidosis and presence of anti-islet cells. A 12-year-old Chinese adolescent boy presented with a two-week history of polydipsia, polyuria, nocturnal enuresis and weight loss.
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