Week 2 - Problem of the Week - EBV and Hodgkins lymphoma and Splenectomy Prophylaxis/Immunizations Flashcards
Clinical Problem Mr E Buchanan, a 20 year old engineering student, presents to your surgery with a one week history of a severe sore throat, malaise, lethargy and sweats. He is also complaining of painful and swollen neck glands. On examination he looks unwell and has several slightly enlarged lymph glands in both cervical regions and significantly enlarged tonsillar nodes. What is the word to describe his nodes?
Lymphadenopathy or adenopathy is disease of the lymph nodes, in which they are abnormal in size, number, or consistency
What are differentials for lymphadenopathy?
Reactive changes - due to bacterial or viral infection Lymphoma or Metastatic cancer Connective tissue/infiltrative diseases is another cause
What are the causes of a raised white cell count, and how does inspection of the differential white cell count help with differential diagnosis
Causes of raised white cell count is mature cells is usually due to a reactive change because of a viral infection or a primary eg due to chronic lymphocytic leukaemia If there is immature cells on blood film then malignancy, sepsis or myelofibrosis Some viruses can cause marrow suppression which keeps with the fact that he has a mild neutropenia an mild thrombocytopenia
What are the common causes of lymphocytosis and neutrophilias?
Neutrophilic leucocytosis -infection (bacterial), inflammatory disorders, trauma/post op - neutrophils are used for wound healing, severe haemorrhage, steroids and MPDs Lymphocytic leucocytosis - infection (viral), CLL, bacteria causing whooping cough in children for some reason causes lymphocytosis
What are atypical lymphocytes and what viruses can cause them?
Atypical lymphocytes - these are lymphocytes that have been activated in response to an infection They lymphocytes change from having a small nucleus and thin rim of cytoplasm to having a large cytoplasm which scallops around red cells EBV is the usual causes (look for anti-EBV antibodies) or can be due to HIV – need to make sure this isn’t missed (viral URTI can also cause these symptoms)
He returns two years later. He has had a dry cough for the last three to four months. In addition, he has developed an irritating itch and is experiencing fevers & sweats especially at night. He has also been experiencing a odd chest discomfort everytime he consumes alcohol. Furthermore, he has lost about 1 stone in weight. On examination he is found to have enlarged lymph nodes in the neck and in both axillae. Lymph node biopsy confirms a diagnosis of classical Hodgkin’s lymphoma. What type of node biopsy is taken?
This would be an excision biopsy of the node
What are the causes of a pancytopenia and how should it be investigated? What does the term leucoerythroblastic mean? and what causes it?
Causes of pancytopenia - Aplastic anaemia, Fanconi’s anaemia, B12/folate, leukaemia/lymphoma The pancytopenia is usually investigated by getting a bone marrow biopsy - hyper or hypo cellular marrow Leucoerythroblastic change - this is where there is the presence of immature white and red cells in the marrow Caused by either reactive changes if sepsis, malignancy (primary or metastatic) and myelofibrosis
What risk factor did this 22 year old have for Hodgkins lymphoma? What are the classic symptoms of hodgkins lymphoma this 22 year old has?
He had a previous EBV infection He is 22 years of age, he has regional lymphadenopathy and has the B type symptoms - weight loss, night sweats He also has alcohol induced pain and pruritus
How is hodgkin’s lymphoma staged? Staging is important for prognosis
Ann-Arbor staging system Stage 1 - one lymph node area involved Stage II - two or more lymph node areas on same side of diaphragm involved Stage III - involvement of lymph nodes above and below the diaphragm Stage IV - involvement outside of lymph node areas
What is the treatment the patient would be on for his Hodgkins lymphoma? Why is he pancytopenic now? What other symptoms arise due to this cause?
Treatment - mutli chemo agents ABVD - Adriamycin, bleomycin, vinblastine and dacarzabine He is pancytopenic as the chemo is causing myelosuppression Other symptoms -hair loss (alopecia), fatigue, nausea, gut mucosal damage
Quick bit on the spleen If the spleen is overacting - may require splenecotmy or if underactive then may also require the same protocols What vaccinations are given prior to splenectomy? What is the prophylactic regime started? What is given if allergic?
Spleen necessary for immunity against encapsulated organism (eg meningococcus, pneumoccus, streptococcus, haemophilus and malaria) If splenectomy – vaccinate patinets for meningococcus, pneumococcus and Hib and give flu vaccine annually and prompt antibiotic prophylaxis Prophylactic antibitoics - pen V (Phenoxymethylpenicillin) - if allergic then eryhtromycin
