감염내과 R2. 김진숙 / Prof. 문수연 복통을 주소로 내원한 Tb lymphadenitis 2 례

CASE 1

정 O 성 (F/28) Adm. 2012/02/11 Chief Complaint Chief Complaint Abdominal paino/s) 내원 3 일 전 Present Illness Present Illness F/28, 특이 병력 없는 자로 내원 3 일 전 Abdominal pain 및 Febrile sensation 로 개인병원 방문하여 약물 복용하였으나 증상 지속되어 응급실 통해 입원함. Location : Epigastric area, periumbilical area Character : 답답하고 뻐근함, NRS 7~8 점 하루종일 지속됨. Agg.factor : 움직일 때, 식사 후

Past medical History Past medical History DM/ HTN/ hepatitis/ Tbc (-/-/-/-) OP Hx.(-) Personal history Personal history Smoking (-) Alcohol (+) : 소주 0.5 병 / 회, 1~2 회 / 월 Familial history Familial history (-)

Review of system Review of system General Febrile sensation (+) : 3 일 전 발생 Chills (-) Weakness (-) Weight loss (+) : -7kg/mon. Skin Rash (-) Itching (-) Pigmentation (-) HEENT Headache (-) Otorrhea (-) Visual disturbance (-) Rhinorrhea (-) Nasal obx.(-) Sore throat (-) Hoarseness (-) Respiratory Cough (-) Sputum (-) Dyspnea (-) Hemoptysis (-) Cardiac Chest pain (-) Palpitation (-) Syncope (-) GI A/N/V/D/C (+/-/-/-) Abdominal pain (+) Hematochezia (-) Melena (-) Hematemesis(-)

Review of system Review of system GU Oliguria (-) Flank pain (-) Hematuria (-) Dysuria (-) Musculoskeletal Weakness(-) Pain(-) Numbness(-)

Physical examination Physical examination Vital sign 110/70mmHg - 78/min - 18/min °C Height: 165 cm Weight: 60 kg BMI 22kg/m 2 Gneral Alert mentality Acute- ill looking appearance HEENT Isocoric pupil c PLR (++/++) Cervical LN enlargement (-) PI (-) PTH (+/+) Thorax Symmetrical chest expansion Clear breathing sound c rale Regular heart beat s murmur Abdomen Soft & flat abdomen Normoactive bowel sound Abdominal Td/rTd (+/-) Muscle guarding(+)

Physical examination Physical examination Back & Ext. Pretibial pitting edema (-/-) CVA Td (-/-) Neurology Motor Sensory 100 ⅤⅤ ⅤⅤ

Initial Lab Finding Initial Lab Finding CBC/DC 8470/mm² g/dl % - 333k (seg. 65.7%) PT (INR) 13.1 sec (0.99) aPTT 36.6 secChemistry TB/DB0.26/0.09 mg/dLBUN/Cr 8/0.9 mg/dl Prot/alb7.1/4.0 g/dLNa/K/Cl 138/4.5/101 mg/dl AST/ALT23/26 IU/LCa/P8.4/2.5 mg/dl ALP/GGT83/51 IU/LCRP 1.83 mg/dlU/A WBC0~1/HPF RBC 2~4/HPF Occult blood - Protein - Nitrate - glucose - pH 5.0 SG 1.010

Chest X-ray

EKG

Problem list Problem list #1. Abdominal pain #2. Febrile sensation #3. Weight loss (-7kg/mon)

Abdominal CT (HD# 1)

Initial assessment & plan Initial assessment & plan #1. Abdominal lymphadenopathy d/t r/o Tuberculous lymphadenitis r/o Kikuchi ‘ s disease r/o Metastatic lymphadenopathy Table 59-1 Diseases Associated with Lymphadenopath y Infectious disease - viral, bacterial, fungal, parasitic… Immunologic diseases - RA, MCTD, SLE… Malignant diseases - Hematologic, Metastatic… Lipid storage diseases - Gaucher’s, Fabry… Endocrine diseases - Hyperthyroidism… Other disorders - Castleman’s disease, Sarcoidosis… (Harrison ’s internal medicine 18 th edition)

Initial assessment & plan Initial assessment & plan #1. Abdominal lymphadenopathy Diagnostic plan) - LN Biopsy, If possible - Gastroscopy, Chest CT 고려 - EBV, CMV, ASO, ANA, p-ANCA, c-ANCA, C3,C4, Ig A/G/M/E Therapeutic plan) 1) Tuberculous lymphadenitis : Tb medication 2) Kikuchi ‘ s diseease : supportive care, observation 3) Metastatic Lymphadenopathy : cancer origin 확인 evaluation 진행

Chest CT (HD# 3)

Laparoscopic LN Bx. (HD #5)

2월8일2월8일 Abdominal pain Febrile sensation Weight loss Abdominal CT Gastroscopy Chest CT 2 월 23 일 퇴원 2 월 18 일 Tb med. start ER 방문 2 월 11 일 Tb IFN (+) LN Bx. : Tb 2 월 15 일 Lap. LN Bx. Abdominal lymphadenopathy

Final Diagnosis Final Diagnosis #1. Abdominal tuberculous lymphadenitis

CASE 2

김 O 수 (M/42) Adm. 2012/01/18 Chief Complaint Chief Complaint Abdominal pain, Fever o/s) 내원 5 일 전 Present Illness Present Illness M/42, 4 년 전 Acromegaly 진단받고 내분비내과 외래 f/u 중인 자로 내원 5 일전 Octreotide 주사 (11 년 6 월 시작, 8 회 째 ) 맞은 다음 날 부터 fever, abdominal pain, rash, 발생하여 입원함. Location : Periumbilical area Character : 쑤씨고 끊어질 듯함, NRS 6~7 점 하루 종일 지속, 악화양상 Agg.factor : 없음 Fever 발생 2 일 후 발견, 악화양상 Location : both lower leg Size: pin-head to bean sized character : Erythematous macule & papulae, purpura

Past medical History Past medical History DM/ HTN/ hepatitis/ Tbc (-/-/-/-) Acromegaly :‘08 년 진단, ‘11 년 pituitary adenoma 수술 Known multiple GB stone :‘08 년 진단 OP Hx.(+) ‘11 년 2 월 pituitary adenoma  Total mass revmoval via trans-sphenoidal approach ‘10 년 8 월 appendectomy Personal history Personal history Smoking (-) ex-smoker (0.5 갑 * 20 년 ) Alcohol (-) Familial history Familial history (-)

Review of system Review of system General Fever(+) Chills (-) Weight loss (-) Weakness (-) Skin Rash (+) Itching (-) Pigmentation (-) HEENT Headache (-) Otorrhea (-) Visual disturbance (-) Rhinorrhea (-) Nasal obx.(-) Sore throat (-) Hoarseness (-) Respiratory Cough (-) Sputum (-) Dyspnea (-) Hemoptysis (-) Cardiac Chest pain (-) Palpitation (-) Syncope (-) GI A/N/V/D/C (-/-/-/-) Abdominal pain (+) Hematochezia (-) Melena (-) Hematemesis(-)

Review of system Review of system GU Oliguria (-) Flank pain (-) Hematuria (-) Dysuria (-) Musculoskeletal Weakness(-) Pain(-) Numbness(-)

Physical examination Physical examination Vital sign 100/70mmHg - 80/min - 20/min °C Height: 183 cm Weight: 73 kg BMI 21.8kg/m 2 Gneral Alert mentality Acute- ill looking appearance HEENT Isocoric pupil c PLR (++/++) Cervical LN enlargement (-) PI (-) PTH (+/+) Thorax Symmetrical chest expansion Clear breathing sound c rale Regular heart beat s murmur Abdomen Soft & flat abdomen Normoactive bowel sound Abdominal Td/rTd (+/-) Muscle guarding(-)

Physical examination Physical examination Back & Ext. Pretibial pitting edema (-/-) CVA Td (-/-) Both leg rash(+) Neurology Motor Sensory 100 ⅤⅤ ⅤⅤ

Initial Lab Finding Initial Lab Finding CBC/DC 9450/mm² g/dl % - 253k (seg. 83.7%) PT (INR) 15.3 sec (1.18) aPTT 42.7 secChemistry TB/DB0.70/0.31 mg/dLBUN/Cr 15/0.8 mg/dl Prot/alb7.2/4.2 g/dLNa/K/Cl 135/4.2/101 mg/dl AST/ALT25/27 IU/LCa/P9.2/4.5 mg/dl ALP/GGT98/81 IU/LCRP 7.28 mg/dlU/A WBC 0~1/HPF RBC 2~4/HPF Occult blood - protein - Nitrate - glucose - pH 5.0 SG 1.018

Chest X-ray

EKG

Problem list Problem list #1. Abdominal pain #2. Fever #3. Both leg rash #4. Known Acromegaly #5. Known Multiple GB stone

Initial assessment & plan Initial assessment & plan #1. Abdominal pain & Fever d/tr/o HSP r/o Cholecystitis, Cholangitis #2. Skin rash d/tr/o HSP r/o Leukocytoclastic vasculitis r/o Polyarteritis nodosa #3. Acromegaly #4.Multiple GB stone

Initial assessment & plan Initial assessment & plan #1. Abdominal pain & Fever d/tr/o HSP r/o Cholecystitis, Cholangitis Diagnostic plan) - Abdominal SONO or Abdominal CT, Chest CT - ANA, p-ANCA, c-ANCA, C3,C4, Ig A/G/M/E Therapeutic plan) 1) HSP : Glucocorticoids (prednisone 1~2mg/kg per day), NASIDs, Supportive care 2) Cholecystitis or Cholangitis : Cholecystectomy, ERCP

Initial assessment & plan Initial assessment & plan #2. Skin rash d/tr/o HSP r/o Leukocytoclastic vasculitis r/o Polyarteritis nodosa Diagnostic plan) - Skin Biopsy, if possible - IgG,M,E,A, C3,C4, ANA, Ferritin, p-ANCA, c-ANCA… Therapeutic plan) 1) HSP : Prednisolone 2) Leukocytoclastic vasculitis : Supportive care 3) Polyarteritis nodosa : Prednisolone, Cyclophosphamide

Initial assessment & plan Initial assessment & plan #3. Acromegaly #4.Multiple GB stone

Abdominal Sono (HD #2)

Abdominal CT (HD #3)

Chest CT (HD #6)

Assessmetn & plan Assessmetn & plan #1. Abdominal Lymphadenopathy d/tr/o Tb lymphadenitis r/o Kikuchi ‘ s disease r/o Metastatic lymphadenitis Diagnostic plan) - LN Biopsy, if possible - Tb IFN-r, EBV, CMV, ASO, ANA, p-ANCA, c-ANCA, C3,C4, Ig A/G/M/E Therapeutic plan) 1) Tuberculous lymphadenitis : Tb medication 2) Kikuchi ‘ s diseease : supportive care observation 3) Metastatic Lymphadenopathy : cancer origin evaluation

Assessment & plan Assessment & plan #2. Leukocytoclastic vasculitis - Supportive care, Observation #3. Acromegaly - Observation #4. Multiple GB stone - Observation

Assessment & plan Assessment & plan #5. Pulmonary Tb, undetermined activity Diagnostic plan) - Sputum Tb PCR, Tb IFN-r, Tb Cx. Therapeutic plan) - Active Tb. 확인 시 medication

Abdominal pain Fever, chills Both leg rash 퇴원 opd f/u Ceftriaxone+ Metronidazol ER 방문 Abdominal sono, Abdominal CT TB med. start TB IFN (+) ERC P Skin Bx. Abdominal lymphadenopath y Chest CT Prednisolone (10mg) LN Bx. 불 가

Final Diagnosis Final Diagnosis #1. Abdominal tuberculous lymphadenitis #2. Leukocytoclastic vasculitis #3. Acromegaly #4. CBD stone with multiple GB stone #5. Pulmonary Tb