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Monstering Humans.Ppt 2003

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Dr.Pradeep Johnson
Dr.Pradeep Johnson

A 49-year-old female PLHA presented with a rapidly enlarging swelling on the right side of her neck over the past 9 months. FNAC and biopsy results showed findings suggestive of lymphoma. She was diagnosed with NHL stage 1 on the right side of the neck and WHO stage 4. Treatment options including chemotherapy first versus starting HAART first were discussed, along with using chemotherapy and HAART simultaneously or treating any OIs first before starting HAART. Sea vegetables were also discussed as a potential complementary treatment due to their anti-cancer properties.

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Big Problem On the Neck Dr.Pradeep Johnson Mentor : Dr.Varuguna Pandian
Chief Complaints A 49 year old female presented with complaint of swelling right side of neck 9 month duration.
H/O Presenting Illness Patient noticed swelling 9 months back on the right side of the neck. 6 months in the size of 25 paisa coin in diameter. Took traditional medicine and noticed rapid increasing swelling in the past 3 months.
H/O Past Illness PLHA since 12/01/2009 with base line CD4 count 142 H/o ATT 2 years back 6 months completed. On CTZ prophylaxis since Jan 2009. No H/o Diabetes, Hypertension, Jaundice. No H/o other OI¡¯S.
Family History Parents ¨C Natural death Siblings ¨C Healthy as per patient Husband had swelling right neck size of an egg treated with chemo therapy. Two children 1 male and 1 female HIV negative
Personal History House wife maintains personal and common hygiene Denies extra marital/ pre marital sexual contacts. Married since 30 yrs
Treatment History On CTZ Prophylaxis since Jan 2009. CAT 1 ATT completed 6 months in 2007 for PT. 3 months back took traditional medicine for right neck swelling.
General Examination Patient conscious, stable, afebrile, moderate built. No Pallor Cyanosis Clubbing Icterus Koilonychia odynophagia / dysphagia / Breathing difficulty Pedal Edema Neurological deficit, Higher mental functions normal Oral cavity ¨C NAD Hard immobile swelling on the right side of neck.
Systemic Examinations CVS : Apex beat normal in position S1 S2 audible, No added sounds RS : Trachea mid line NVBS No raised JVP P/A : Soft, No organomegaly CNS : NAD
Vital Signs BP : 110/70 mm Hg Pulse : 80/min Temperature : Normal Height : 165 cm Weight : 65 kg BMI : 19
UGS Abdomen & Pelvis Normal Study
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Local Examination Hard immobile enlarged lymph node right side of neck occupying pre auricular / right mandible/posterior mid line of neck/ till right clavicle and right trapezium. Non tender No warmth
Summary A 49 yr old female PLHA since Jan/2009,on CTZ prophylaxis with base line CD4 142 cells, past H/o ATT 6 months completed 2 yrs back. Presented with c/o swelling Rt side of neck 9 months duration, rapid increase in swelling past 3 months,H/o traditional medicine 3 months back.
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Investigations CBC RBS LFT RFT Sputum AFB Mantoux Test X-ray chest PA view
Test Results HB 9.6 g/dl WBC 2.0 10 x cu mm RBC 3.94 10 x cu mm RBS 113 mg/dl UREA 14 mg/dl CREATININE 0.7 mg/dl AMYLASE 126 u/l PROTIEN TOTAL 8.5 g/dl ALBUMIN 3.1 g/dl GLOBULIN 5.4 g/dl
Test results cont¡­. BILIRUBIN 0.4 mg/dl SGOT 70 u/l SGPT 36 u/l ALK PHOSPHATASE 135 u/l MANTOUX NEG SPUTUM AFB NEG (3 smears) LDH 270 u/l
Differential Diagnosis?
Differential Diagnosis Solid tumor malignancies Metastatic disease to lymph nodes secondary to carcinoma, melanoma, or sarcoma Other hematologic malignancies or lymphoproliferative disorders Granulocytic sarcoma Multicentric Castleman disease Benign lymph node infiltration or reactive follicular hyperplasia secondary to infection (eg, tuberculosis; other bacterial, fungal, and, rarely, viral infections), and collagen-vascular diseases
FNAC Microscopy : cellular smears studied show many large lymphocytes aggregate of histiocytes in a hemorrhagic back ground. Impression : Suggestive of lympho-proliferative disorder Done 3 months back at SALEM
Histopathology Specimen : Rt side of neck lymph node biopsy Impression : Suggestive of malignant round cell tumor Rt side of neck lymph- node biopsy Comments : Non-Hodgkins lymphoma
Final Diagnosis PLHA Ann Arbor stage 1 lymphoma Rt side of neck WHO stage 4
Discussion First HAART / Chemotherapy? What are the merits and demerits in starting HAART first? Could we start HAART/Chemotherapy simultaneously? Comment on treat OI first and Initiate HAART?
HAART signicantly lowers risk of non-Hodgkin's lymphoma for up to ten years, regardless of nadir CD4 count They found that the highest incidence of non-Hodgkin¡¯s lymphoma (13.6 per 1000) took place in the pre-HAART era (1993-1995). During the period, 2002-2006, the incidence declined to a low of 1.8 per 1000. Thus,¡± they conclude, ¡°although it was already clear that HAART prevents [non-Hodgkin¡¯s lymphoma] through improvement of immune status , this study shows that HAART avoids the majority of [non-Hodgkin¡¯s lymphoma], even among the most severely immunosuppressed individuals.¡± Reference Polesel, J et al. Non-Hodgkin¡¯s lymphoma incidence in the Swiss HIV Cohort Study before and after highly active antiretroviral therapy. AIDS 22(2), 301-306, 2008 .
Chemotherapy Chemotherapy first: Merits controls neoplastic cell division, tolerance to ART may be improved Demerits delay the initiation of ART higher risk of other OI risk of IRIS (once started on ART)
HAART HAART first Merits Increased immunity against neoplastic antigen Demerits intolerance Low or non adherence
Types lymphoma T- cell lymphoma B- cell lymphoma B- cell lymphomas are 10 time common than T-cell lymphoma
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High Grade NHL Diffuse large B-cell lymphoma Adult T-cell leukaemia / lymphoma Anaplastic large T-cell lymphoma Angioimmunoblastic lymphoma (AIL) Burkitt¡¯s lymphoma Enteropathy associated T-cell lymphoma (Intestinal T-cell lymphoma) HIV and AIDS related lymphoma Intestinal T-cell lymphoma Lennerts lymphoma Lymphoblastic lymphoma Mantle cell lymphoma Mediastinal diffuse large b-cell lymphoma Nasal type T ¨C cell lymphoma Peripheral T-cell lymphoma Primary central nervous system lymphoma
Stages and Prognosis
Courtesy : www.lrf.org.uk
Courtesy : www.lrf.org.uk
TREATMENT Chemo-therapy Radio-therapy Stem cell transplantation Steroid therapy Biological therapy Radio-immuno therapy Complementary therapy Courtesy: www.cancercouncil.com.au
Chemo-therapy Two of the most common combinations are 'CHOP' and 'CVP¡®. 'CHOP' is a combination of three chemotherapy medications plus prednisolone, and stands for: Cyclophosphamide Hydroxydaunorubicin (also sometimes known as adriamycin or doxorubicin) vincristine Prednisolone CVP', involves just cyclophosphamide, vincristine and prednisolone
Stem cell Therapy Courtesy: www.cancercouncil.com.au
Marine Treasure
Sea Vegetables helps in treatment and prevention of neoplasm?
Sea Vegetables Classified by pigment composition - Blue algae (rocks) - Green algae (shallow water) - Brown algae (Intermediate depth) - Red algae (deeper water) Grow by photosynthesis Fucoidan response for slippery and gluey nature of sea vegetables Fucoidan ¨C sulphated polysaccharide with glucose called ¡°FUCOSE¡±
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Teas J , Hebert JR , Fitton JH , Zimba PV . Health Promotion Education and Behavior, The Norman J Arnold School of Public Health, University of South Carolina and the South Carolina Cancer Center, 15 Medical Park, Suite 301 Columbia, SC 29203, USA. jane.teas@palmettohealth.org
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ACKNOWLEDGEMENTS The Superintendent , GHTM Medical Director, I TECH RMO, GHTM All Mentors, GHTM Chief fellow I TECH Faculty Fellows
Thank YOU !

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Monstering Humans.Ppt 2003

  • 1. Big Problem On the Neck Dr.Pradeep Johnson Mentor : Dr.Varuguna Pandian
  • 2. Chief Complaints A 49 year old female presented with complaint of swelling right side of neck 9 month duration.
  • 3. H/O Presenting Illness Patient noticed swelling 9 months back on the right side of the neck. 6 months in the size of 25 paisa coin in diameter. Took traditional medicine and noticed rapid increasing swelling in the past 3 months.
  • 4. H/O Past Illness PLHA since 12/01/2009 with base line CD4 count 142 H/o ATT 2 years back 6 months completed. On CTZ prophylaxis since Jan 2009. No H/o Diabetes, Hypertension, Jaundice. No H/o other OI¡¯S.
  • 5. Family History Parents ¨C Natural death Siblings ¨C Healthy as per patient Husband had swelling right neck size of an egg treated with chemo therapy. Two children 1 male and 1 female HIV negative
  • 6. Personal History House wife maintains personal and common hygiene Denies extra marital/ pre marital sexual contacts. Married since 30 yrs
  • 7. Treatment History On CTZ Prophylaxis since Jan 2009. CAT 1 ATT completed 6 months in 2007 for PT. 3 months back took traditional medicine for right neck swelling.
  • 8. General Examination Patient conscious, stable, afebrile, moderate built. No Pallor Cyanosis Clubbing Icterus Koilonychia odynophagia / dysphagia / Breathing difficulty Pedal Edema Neurological deficit, Higher mental functions normal Oral cavity ¨C NAD Hard immobile swelling on the right side of neck.
  • 9. Systemic Examinations CVS : Apex beat normal in position S1 S2 audible, No added sounds RS : Trachea mid line NVBS No raised JVP P/A : Soft, No organomegaly CNS : NAD
  • 10. Vital Signs BP : 110/70 mm Hg Pulse : 80/min Temperature : Normal Height : 165 cm Weight : 65 kg BMI : 19
  • 11. UGS Abdomen & Pelvis Normal Study
  • 12. ?
  • 13. ?
  • 14. ?
  • 15. Local Examination Hard immobile enlarged lymph node right side of neck occupying pre auricular / right mandible/posterior mid line of neck/ till right clavicle and right trapezium. Non tender No warmth
  • 16. Summary A 49 yr old female PLHA since Jan/2009,on CTZ prophylaxis with base line CD4 142 cells, past H/o ATT 6 months completed 2 yrs back. Presented with c/o swelling Rt side of neck 9 months duration, rapid increase in swelling past 3 months,H/o traditional medicine 3 months back.
  • 17. ?
  • 18. ?
  • 19. ?
  • 20. Investigations CBC RBS LFT RFT Sputum AFB Mantoux Test X-ray chest PA view
  • 21. Test Results HB 9.6 g/dl WBC 2.0 10 x cu mm RBC 3.94 10 x cu mm RBS 113 mg/dl UREA 14 mg/dl CREATININE 0.7 mg/dl AMYLASE 126 u/l PROTIEN TOTAL 8.5 g/dl ALBUMIN 3.1 g/dl GLOBULIN 5.4 g/dl
  • 22. Test results cont¡­. BILIRUBIN 0.4 mg/dl SGOT 70 u/l SGPT 36 u/l ALK PHOSPHATASE 135 u/l MANTOUX NEG SPUTUM AFB NEG (3 smears) LDH 270 u/l
  • 24. Differential Diagnosis Solid tumor malignancies Metastatic disease to lymph nodes secondary to carcinoma, melanoma, or sarcoma Other hematologic malignancies or lymphoproliferative disorders Granulocytic sarcoma Multicentric Castleman disease Benign lymph node infiltration or reactive follicular hyperplasia secondary to infection (eg, tuberculosis; other bacterial, fungal, and, rarely, viral infections), and collagen-vascular diseases
  • 25. FNAC Microscopy : cellular smears studied show many large lymphocytes aggregate of histiocytes in a hemorrhagic back ground. Impression : Suggestive of lympho-proliferative disorder Done 3 months back at SALEM
  • 26. Histopathology Specimen : Rt side of neck lymph node biopsy Impression : Suggestive of malignant round cell tumor Rt side of neck lymph- node biopsy Comments : Non-Hodgkins lymphoma
  • 27. Final Diagnosis PLHA Ann Arbor stage 1 lymphoma Rt side of neck WHO stage 4
  • 28. Discussion First HAART / Chemotherapy? What are the merits and demerits in starting HAART first? Could we start HAART/Chemotherapy simultaneously? Comment on treat OI first and Initiate HAART?
  • 29. HAART signicantly lowers risk of non-Hodgkin's lymphoma for up to ten years, regardless of nadir CD4 count They found that the highest incidence of non-Hodgkin¡¯s lymphoma (13.6 per 1000) took place in the pre-HAART era (1993-1995). During the period, 2002-2006, the incidence declined to a low of 1.8 per 1000. Thus,¡± they conclude, ¡°although it was already clear that HAART prevents [non-Hodgkin¡¯s lymphoma] through improvement of immune status , this study shows that HAART avoids the majority of [non-Hodgkin¡¯s lymphoma], even among the most severely immunosuppressed individuals.¡± Reference Polesel, J et al. Non-Hodgkin¡¯s lymphoma incidence in the Swiss HIV Cohort Study before and after highly active antiretroviral therapy. AIDS 22(2), 301-306, 2008 .
  • 30. Chemotherapy Chemotherapy first: Merits controls neoplastic cell division, tolerance to ART may be improved Demerits delay the initiation of ART higher risk of other OI risk of IRIS (once started on ART)
  • 31. HAART HAART first Merits Increased immunity against neoplastic antigen Demerits intolerance Low or non adherence
  • 32. Types lymphoma T- cell lymphoma B- cell lymphoma B- cell lymphomas are 10 time common than T-cell lymphoma
  • 33. ?
  • 34. High Grade NHL Diffuse large B-cell lymphoma Adult T-cell leukaemia / lymphoma Anaplastic large T-cell lymphoma Angioimmunoblastic lymphoma (AIL) Burkitt¡¯s lymphoma Enteropathy associated T-cell lymphoma (Intestinal T-cell lymphoma) HIV and AIDS related lymphoma Intestinal T-cell lymphoma Lennerts lymphoma Lymphoblastic lymphoma Mantle cell lymphoma Mediastinal diffuse large b-cell lymphoma Nasal type T ¨C cell lymphoma Peripheral T-cell lymphoma Primary central nervous system lymphoma
  • 38. TREATMENT Chemo-therapy Radio-therapy Stem cell transplantation Steroid therapy Biological therapy Radio-immuno therapy Complementary therapy Courtesy: www.cancercouncil.com.au
  • 39. Chemo-therapy Two of the most common combinations are 'CHOP' and 'CVP¡®. 'CHOP' is a combination of three chemotherapy medications plus prednisolone, and stands for: Cyclophosphamide Hydroxydaunorubicin (also sometimes known as adriamycin or doxorubicin) vincristine Prednisolone CVP', involves just cyclophosphamide, vincristine and prednisolone
  • 40. Stem cell Therapy Courtesy: www.cancercouncil.com.au
  • 42. Sea Vegetables helps in treatment and prevention of neoplasm?
  • 43. Sea Vegetables Classified by pigment composition - Blue algae (rocks) - Green algae (shallow water) - Brown algae (Intermediate depth) - Red algae (deeper water) Grow by photosynthesis Fucoidan response for slippery and gluey nature of sea vegetables Fucoidan ¨C sulphated polysaccharide with glucose called ¡°FUCOSE¡±
  • 44. ?
  • 45. ?
  • 46. Teas J , Hebert JR , Fitton JH , Zimba PV . Health Promotion Education and Behavior, The Norman J Arnold School of Public Health, University of South Carolina and the South Carolina Cancer Center, 15 Medical Park, Suite 301 Columbia, SC 29203, USA. jane.teas@palmettohealth.org
  • 47. ?
  • 48. ?
  • 49. ?
  • 50. ACKNOWLEDGEMENTS The Superintendent , GHTM Medical Director, I TECH RMO, GHTM All Mentors, GHTM Chief fellow I TECH Faculty Fellows