A middle aged man with severe weight loss &

increasing breathlessness

Dr . ABU JAR GAFFAR MD Final Part student Department of Endocrinology

BSMMU

Patient Profile

• Mr. X• 51 year• Ex smoker• farmer • D/A : 01/06/13

Presenting Complaints

•Cough & shortness of breath – 1 ½ yrs

•Swelling in front of the neck – 1 ½ yrs

•Swelling of both legs – 1 month

History of presenting complaints

Shortness of breath

Start 1 ½ yrs back but increased for last 1 month

Exertional

Awakes from sleep at night

associated with cough occassionally productive,

scanty, whitish with no haemoptysis

no chest pain & having no seasonal variation

History of presenting complaints•Swelling of both legs

progressive reduced urine volume associated with SOB & cough no yellowish urine or sclera or

haematuria

History of presenting complaints•No H/O fever

•But significant weight loss of about 20 kg in last 1 and ½ years.

History of presenting complaints• Diagnosed as a case of Graves thyrotoxicosis

with heart failure on December 2011 on basis of Weight loss heat intolerance increasing bowel habit ( no blood,

mucous, tenesmus, normal in color & amount) painless diffuse neck swelling

SOB, tender hepatomegaly, bilateral leg edema &

Positive biochemical findings

•He was prescribed with carbimazole, captopril, diuretics & was improving gradually.

•But he was on irregular follow up & stopped all medications for last 3 months & subsequently getting worse day by day

Other history• H/O sudden severe chest pain on 2006 , got

admitted in NIDCH, diagnosed as primary spontaneous pneumothorax ( lt), improved with tube thoracostomy

• No H/O TB or contact with TB patients.

• Ex smoker - 20 pack year - Cessation of smoking for last 1

yr due to his illness - No h/o taking inhaler

No one in his family suffering from same type of illness

Low socioeconomic

Physical examination

General Examination• Anxious, cachectic• Mildly anaemic non icteric• Generalized lymphadenopathy involving lt anterior

cervical, Both supraclavicular & medial group of axillary - largest in left axilla (3X2 cm)

- non tender, firm, discrete, mobile. No discharging sinus

• Bil pitting leg edema

General Examination

• JVP : Raised

• Hands : warm, not sweaty, Fine tremor +

• Pulse : 88 bpm

• BP : 120/65 mm of HG

• RR : 24/min

• Temp : Normal

• Thyroid :

Enlarged, diffuse

soft, non tender, mobile

no retrosternal extension

thyroid bruit - present

Systemic examination▫ Respiratory system :

▫ Barrel shaped chest

▫ Breath sound is vesicular with prolonged expiration

▫ Bilateral basal crackles

▫ No evidence of Pleural effusion

▫ Abdomen :

• Liver is palpable 7 cm from right costal margin

along the right midclavicular line, firm, non-tender, smooth surface, regular margin, upper border in rt 6th intercostal space liver span 14 cm

• No Splenomegaly & ascites

Systemic examination▫Cardiovascular system

▫ Apex beat shifted in lt 6th intercostal space, 12 cm from midline, no gallop rhythm, no murmur

▫Nervous system

▫ normal

Differential diagnosis

• Graves thyrotoxicosis with COPD with Heart failure with disseminated TB

• Graves thyrotoxicosis with COPD with Heart

failure with lymphoma

Investigations

CBCDate Hb TC DC ESR

31/01/12 10.5 gm/dl 65

•30.05.13

FT4 7.15 ng/dl (0.8 – 1.5 ng/dl)

TSH 0.004 uIU/ml (0.35-5.8 uIU/ml)

•Chest Xray P/A ( 04.06.13):

Inhomogenous opacity with fibrotic band shadows noted in upper & mid zone of Rt lung field, calcification is in upper zone of rt lung suggestive of sequlae of (rt) pul TB

Rt sided pleural reaction

03.06.13

S. Albumin 30 gm/ltS. Creatinine 0.7 mg/dlS. Na 151, K 3.5, Cl 107, TCO2 25 mmol/L

•Reports awaiting

CBC

Tuberculin test

ECG, Echocardiogram

Spirometry

USG of W/A

Disseminated TB:

Points in favour Points against :

Wt loss

Generalized

lymphadenopathy

Radiographic change

hepatomagaly

Weight loss & lymphadenopathy may be due to Graves disease

No fever

Lymh nodes are not matted

No ascites

No H/O contact with TB patients

LymphomaPoints in favour Points against :

Severe weight loss

Generalized Lymphadenopathy

Lymphnodes are not rubbery

No spenomegaly , ascites

Problems

•Diagnostic dilemma

•Is it necessary to perform any more further investigations to reach the diagnosis?

•What will be the further management?