A 56yr old male came with C/O fever since 2 months
Patient was apparently asymptomatic 2 months back and then have fever, high grade, associated with mild chills and rigor. ( 100°F —> 104°F) associated with cervical lymphadenopathy.
Not associated with Cold, Cough, Headache, Bodypains.
K/C/O DM since 30 years (on medication Glicazide 80mg + Metformin Hydrochloride 500 mg)
Not a K/C/O HTN, Asthma, Thyroid disorders, Epilepsy.
Family History of DM ( Father, Grand Father and Great Grandmother ) + . Now his son (aged 29 years) also diagnosed with DM 4 months back
Patient is a publisher by occupation though he completed BAMS. He is very passionate about his work and never neglected his work for any reasons. He used to do alot of physical work before but Now he hired other persons to do the work to reduce work stress and do monitor their work.
Since Childhood (around 3 years of age), he is using spectacles for nearsightedness (myopia). From then to till date his power remained same.
At the age of 4 years(In 1970), Patient’s father noticed a small swelling (asymptomatic) on the right side of the neck for the first time and then they went to local hospital where they said it was a lymph nodal swelling for which treatment was taken and size was reduced.
He married at the age of 14 years. (Third degree consanguinity)
At the age of 27 years, patient had a history of fall from bus because of giddiness for which he was taken to hospital and high blood sugars were noted.Then he was diagnosed with DM for which medication was prescribed and he used it for around 1week. Later, he started homeopathy medication for 2 n1/2 years and then stopped as his sugars levels were in control. After the fall incident, where he sustained head injury and from the very next day he had memory loss for 6 months. ( patient just remembered he had a fall because of giddiness and then went home, talked to his wife about paying fare to his transport - auto driver who helped him then. On the following morning after he woke up he din’t remember his wife/kids ). Till now he had no memory of those 6 months.
At the age of 50 years, he again started Anti diabetic medication (his present medication) as his sugars were quite high. Started with taking 1/2 tablet BD and then increased to 1 tablet BD and present taking 1n1/2 tab in the morning and 1 tablet in the night.
Again in 2018, patient noticed swelling on the right side of the neck which was progressive for 3-4 months to the present size. It was painless. He was on medication ( probably ? ATT) for 2 months ( prescribed by family doctor). They used medication for 1 month and later they din’t have the access to get the medication as it was unavailable (then patient came to know he was using some high medication) . Then for the second month he was advised to register with red cross and done the same where he then got the medicine based on his old prescription. 4 months later, Montoux test was done which came negative. He continued the same medication for 1 year. After that, again montoux test was done at government hospital which was negative again where then they advised to stop the medication as he was on wrong (unnecessary) prescription.
Then FNAC was done which suggests - Granulomatous Lymphadenitis (possibly of koch’s etiology)
And then patient came to know he has No TB.
In 2021, patient’s father was deceased ( patient was very close with his father, felt depressed and sad then) ,he had to attend some religious rituals for 13 days where he was non compliant with anti diabetic medication.
Later in March 2022, he went to hospital for the complaints of fever, high grade and they said it was associated with his swelling for which CT scan of chest and Bronchoscopy was done. He then took TAB CEFTUM for 7 days which he felt was not effective for him. Since March, he used to take DOLO 650mg everyday 8th hourly. He took little food as it was not felt good on tasting and sometimes it was nauseous on intake of rice. His appetite is normal along with fluid intake. He lost around 14 kgs of weight.
In April 2022, he came to our hospital with complaints of fever everyday which was high grade and then admitted for biopsy which was not done as patient had to attend some personal works. There he got fever and local doctor prescribed MEFTAL and patient got no fever for 3 days. Then he again got fever on following 4th day and took MEFTAL again along with TAB AUGMENTIN BD on 25th april for which he got no fever till date. He was admitted here again on 28th april
Chest X ray
ECG
USG NECK
Hemogram :
CUE :
LFT :
Blood urea - 16 mg/dl
Serum creatinine - 0.7 mg/dl
Na+ - 140 mEq/L
K+ - 5.0 mEq/L
Cl- 100 mEq/L
RBS - 223 mg/ dl, FBS -100mg/dl, PLBS - 178mg/dl
Absolute Eosinophil Count - 200 cells/cumm
Provisional diagnosis -
Pyrexia of Unknown Origin with Right Cervical Lymphadenopathy
? Kochs
?Sarcoidosis
? Lymphoma
Treatment :
TAB DOLO 650mg PO/TID
TAB AUGMENTIN 625mg PO/BD
TAB PRIZIDE - M80 1n1/2 tab—X—-1tab
(Glicazide 80mg +Metformin 500mg)
