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Headache, enlarged abdomen. CXR showed prominence of hilar lymph nodes. Want opinion

hi sir im a resident physician , we have this clinicopathologic conference case here, i would just like to ask your opinio with our case...hope you can help us with the diagnosis and differentials.... General Data This is a case of a 27 year old female, single, Catholic from Samar, admitted for the first time due to severe throbbing headaches and enlargement of the abdomen. History of Present Illness Condition started 8 months PTA, when she suddenly felt severe throbbing headaches while lying down, occurring alternately between the right and left sides of the head, lasting approximately an hour with associated nausea. The pain would be slightly relieved by Paracetamol . This was also associated with blurring of vision. The patient was noted to have light perception , but other figures were described as “cloudy”. There was also notable enlargement of the abdomen prior to headaches, no change in the frequency of bowel movement (defecates every other day) as claimed by the patient. She denied of any intimate contact. Seven months PTA, the headache and nausea persisted, this time associated with dizziness. Symptoms progressed until 5 months PTA, when the patient consulted a neurologist . She was diagnosed to have an intracranial tumor. Ophthalmologic examination was also sought by the patient. She was also referred to a surgeon and gynaecologist for the evaluation of abdominal enlargement. There were episodes of difficulty in urination, more felt at the latter part of voiding. Four months PTA, consultation was done in another institution. A skull x-ray was taken and was found to be unremarkable. A cranial MRI examination was advised to patient but deferred due to financial constraints. 1 week PTA, the cranial MRI was eventually done and the patient was subsequently advised admission. Ultrasound of the abdomen was also done which revealed a large complex mass in the left ovary. Review of Systems (+) unquantified weight loss (-) loss of consciousness (-) cough nor colds (-) dyspnea (+) easy fatigability (+) slight chest pain (+) slight tenderness on the abdomen (+) dysuria (-) bleeding tendencies Personal History: occasionally smokes 3-8 sticks per day since 18 years old. Family History: (+) Hx of diabetes mellitus , hypertension, and emphysema Past Medical History: No previous asthma, no food and drug allergies; S/P appendectomy 2 years ago Physical examination: conscious, coherent, ambulatory individual who was not in respiratory distress Weight: 46kg, Height 5’3”  BMI: 17.99 Vital signs: BP 120/70, PR 72/min, RR 28/min, Temp 37.9C SHEENT: (+) pale palpebral conjunctivae, anicteric sclerae, no naso-aural discharge; tonsils and posterior pharynx were slightly hyperemic with thin film of yellowish secretion, neck was supple, no palpable lymph nodes. Chest/Lungs: (+) symmetrical in expansion, with prominent rib cage, (-) retractions and clear breath sounds. The breasts are symmetrical but there was a palpable nodule approximately 4cm which is movable with delineated borders. Heart: precordium was adynamic with normal rate and rhythm Abdomen: globular with fundic height of 29cms, slightly tender, no fluid wave, vague bowel sounds Extremities: No gross deformities noted, Pulses were full and equal. Course in the Ward: On admission, CBC showed anemia of 8.0mg/dL, leukocytosis of 13,000/, platelet count of 284,000. Two units of FWB were transfused. Urinalysis revealed sugar - negative, albumin - 3+, pus cells - 50/hpf. Blood chemistries showed: Blood Chemistry Results FBS 120mg/dL BUN 24mg BUA 5.5mg/dL Creatinine 1.4mg/dL Total Cholesterol 179mg/dL Triglycerides 125mg/dL HDL 55mg/dL LDL 120mg/dL ALT 24mg/dL AST 21mg/dL CXR: slight prominence of the hilar lymph nodes with minimal infiltrates The patient still experienced throbbing headaches, still feverish and was given antipyretics and was hooked with IV line. On the 2nd hospital day, nephrology consult was done for proteinuria. Ultrasound of the kidney, urinary bladder, liver, gallbladder, biliary tree, pancreas and spleen showed these organs to be normal. Ultrasound of the pelvic organs revealed an enlarged complex left ovarian mass. There was a low-grade fever with throbbing headaches notably milder than the 1st day. On the 4th hosp day, the throbbing headaches still persisted. CT scan revealed an extra-axial tumor with few calcification and cysts formation, probably benign. She was scheduled for CP clearance prior to surgery. On the 5th hosp day, the patient was still febrile, given antibiotics and antipyretics. A few hours later, the patient experienced headaches not relieved by NSAIDs. On the 7th hosp day, high grade fever recurred, notably drowsy, anasarcous with no significant change in the urine output. Blood chemistries showed hypernatremia, hypokalemia, hypoalbuminemia, hyperglycemia and elevated levels of AST. Potassium replacement was done. Insulin was also given. Few hours later, the patient became stuporous and hypotensive with coarse rales from mid to base on both lung fields. Dobutamine and epinephrine were started. She was subsequently intubated. On the 8th hosp day, the patient remained febrile and hypotensive. Furosemide was given and titrated due to further increasing abdominal girth and edema of the face and extremities. Fluconzaole 200mg/NGT OD was started. Patient unfortunately expired several hours later.
Asked On : Tue, 23 Oct 2012
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Pathologist and Microbiologist 's  Response
Hello and welcome to HCM,

I will try to focus on the positive findings in your long and exhaustive history.
1. The head aches associated with 'aura'- nausea, visual disturbances, pain relieved by paracetamol suggest migraine. An extra axial tumor with calcification and cysts (? meningioma) can also produce headache, focal neurological symptoms but 'aura' is less likely to be associated with a brain tumor.
2. There is a history of painful abdominal mass, uterine enlargement and detection of a complex ovarian mass on the left side abdomen. This is likely to be an ovarian tumor. Constitutional features- weight loss, fatigue are constitutional symptoms associated with malignancy. So, the second most probable pathology was an ovarian tumor.
3. Hyperemic pharyngeal mucosa suggests focus of infection due to which the patient was febrile.
4. Biochemical abnormalities- hypernatremia, hypokalemia, hypoalbuminemia and albuminuria suggests renal pathology.
Albuminuria is a feature of glomerular membrane damage.
Hypernatremia and hypokalemia are seen in tubulo-interstitial diseases.
So, these findings suggest pathology of all compartments of the kidney.
Hypokalemia is a dangerous condition.
As you have mentioned that, potassium replacement had been given, however, a recurrent fall in potassium levels can cause dangerous arrthymias and sudden death.
Moreover anasarca suggests a decompensated kidney.
Ovarian tumor or a brain tumor are unlikely to cause sudden death.

I hope my answer is of some help to you.
Thanks and take care
Dr Shailja P Wahal

Answered: Tue, 11 Jun 2013
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