Case #6

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23-year-old HIV positive black male admitted to hospital with complaints of difficulty breathing at night while lying flat in bed. Admitted to hospital after fainting while stooping over. Approximately one month prior to admission, developed cold and non-productive cough. In past six weeks, drenching night sweats and fever (greater than 39 °C) occurred regularly.

Expand Physical Exam


Knot-like swelling in left neck that hurts when he coughs. Bilateral anterior cervical adenopathy. HEENT normal except knot, except thyroid not palpated. Throat normal. Chest had slight dullness to percussion. Abdomen soft, nontender. Spleen tip not palpable. No other masses or tenderness.

Expand Imaging


CXR: Bilateral hilar and mediastinal enlargement most likely due to lymphadenopathy. Findings are compatible with a lymphoma mass compressing the trachea.
Gallium scan: Massive lymph node involvement in mediastinum and possible
lymph node involvement in periaortic regions.
Liver-spleen scan: no changes suggestive of metastases.
IVP: Normal
Abdominal CT scan: definite periaortic lymphadenopathy consistent with below-the-diaphragm involvement by lymphoma.

Expand Endoscopy


Mediastinoscopy: Matted nodes in mediastinum compressing the trachea.

Expand Operation


Biopsy of left neck knot

Expand Pathology


Large cell follicular lymphoma, left neck


Endoscopic biopsies of mediastinum: large cell follicular lymphoma


Bone marrow aspiration biopsy, right superior iliac crest: negative for tumor

Expand Treatment


Palliative radiation therapy to superior mediastinum (1000 rads)


Started R-CHOP regimen (rituximab, cyclophosphamide, doxorubicin, vincristine, prednisone)