This is a story of patient who has followed advice of her
doctor religiously. Has been subjected to 3 months of anxiety ,lot of
expenses & foot balling.
Mrs Liaqat Ali Sahiba 35 years old , married, mother of 4 children. Wife of
Mathematics Professor in Islamia College Gujranwala.
14 4 98
Presented for PUO for last 3 months, in addition to vomiting & generalized
abdominal pain more in the epigastric region. Fever was preceded by D& C for
miscarraige. History did not indicate completely previous drug intake.
Typical response of a Family physician
Prescribed Ciproxin 500 mgs BID, & gravinate bid. for 7 days
20 4 98
Incomplete response. Fever still there.
Prescribed DALACIN C 300 tid, Flagyl tab 400 tid, Idarac tid.
24 4 98
No relief, Investigated.with following results.
USG = Liver slightly increased. Fluid in the pelvis. Rt ovarian cyst.
CBC= ESR 114, TLC 2800, DLC = NAD, Urine = Haemoglobinuria Colour of serum
is normal, making LFTs most probably normal.
XR chest PA & Lat views = Mass in the Ant Superior Mediastinum.
R = ATT & refered to medical specialist for the mass & further
investigations for PUO.
28 4 98
Peritoneal. Fluid was aspirated & sent for examinaton. Differential
Diagnosis in the mind of consultant was Thymoma associated with
immunodefeciency.
Radiologist also was firm in his opinion that mass in the mediastinum was
Thymus.
Fluid was exudate.
Flouriscent stain for M.Tuberculosis was negative by Shaukat Khanum
Lab.Patient was advised CT scan for mass in the thorax.
LFTs are advised first time. These are normal except small rise in serum Alk
Phosphatase.CBC is repeated for the first time. Same results.
Blood culture is negative.ATT is disconticued.
6 5 98
Immunoglubulins are done by Aga Khan Lab. These are normal.
5 5 98
CT scan abdomen reported .
Minimal amout of ascites. Matted bowel loops in the mid & lower abdomen.
Possibility of Tuberculosis should be kept in mind.
9 5 98
CT Scan Chest = Pleural effusion on left side. No mass in the mediasitnum
was seen.
14 5 98
Urine, CBC & LFTs are again repeated. Same results.
16 5 98
Pleural effusion is tapped. Fluid sent for routine examination. It is an
exudate. Mycodot is negative .
Biopsy of Pleural tissue is negative. No granuloma seen.
18 5 98
USG is repeated. Same result.
3 6 98
CA 15 3, 125,& CEA & throglobulin are advised to rule out malignancy. All
are normal.
15 6 98, 10 7 98
USG repeated twice. Same results.
9 7 98
Advised consultation with Dr Zahida Durrani who advised diagnostic Lapratomy.
Prof Nasim Niaz did Laprotmy in Lady Willington Hospital. Report.
Peritonium covering Ant abdominal wall, pelvis, Uterus ,under surface of
Liver & Diaphragm is studded with small pinhead to ½ inch diameter lesions
probably from malignancy. Omentum is also fully covered. Loops of intestine
are matted together & studded with similar lesions. A thorough search for
Primary is made. No success.
Finally the diagnosis
Pathologist gives a firm opinion that these are chronic granulomatous
tubercular lesions. No evidence of malignancy. She is doing well on ATT now.
Conclusion.
1 Therapeutic trial of ATT was indicated after initial investigations.
2 if patient have to be investigated then these are the parameters & the
extent to be followed.
3 Usg CBC LFTs urine were repeated so many times due to