Case report
An 18-year-old man who has been suffering from myalgia, cough, and
anorexia for about 11 days has been referred to our hospital with severe
abdominal pain, yellowing of the eyes, and myalgia. The onset of
persistent abdominal pain 6 days ago was sudden in the epigastric and
pre-embolic areas, which were non-radical and non-positional and did not
improve with eating. The patient then reports three episodes of anemic
vomiting containing food in the last 6 days. During the last 3 days, the
patient’s abdominal pain intensified and spread to LUQ, and he developed
jaundice and red lesions on the chest and abdomen. The night before
going to the hospital, he also mentioned fever and chills. Symptoms
included cough, dry mouth, skin rash on the chest and abdomen, petechiae
in the abdominal area above the navel and chest, icteric sclera, dry
nose, flank pain, and facial edema. The patient does not report symptoms
of shortness of breath, orthopnea, and PND. Erythema of the pharynx and
tonsils and bilateral submandibular lymphadenopathy was also observed,
and the thyroid gland was normal to the touch and lacked tenderness and
nodularity. Other examinations of the body system were also normal and
had no significant results. The patient also mentions an unknown weight
loss history during the last 3 months. There is no significant medical
history, except for the history of COVID-19 3 months ago, which was
treated at home and without hospitalization, and the onset of cold
symptoms a week ago, which was accompanied by runny nose and cough. The
history of taking a particular drug is not mentioned. Examinations of
the patient showed dry mouth and red rashes on the chest and abdomen
with fever and chills. On examination of the patient’s abdomen, the
intestinal sounds were normal and about 8-9 cm was measured liver span
and the spleen was 3 cm below the edge of the rib and despite the
tenderness observed in the epigastrium and periumbilical region and LUQ,
no mass was touched on superficial and deep touch.
Laboratory tests showed a decrease in platelet count (19000 per
microliter) and amylase (25 U/L) and a sharp increase in white blood
cells (14,400 per microliter), 80% of which were lymphocytes, and
atypical lymphocytes were also observed. Alkaline phosphatase (ALP) 686
IU/L, Aspartate aminotransferase 93 U/L, ALT 75 U/L and Lactate
Dehydrogenase (LDH) 4280 U/L were observed along with bilirubin total
12.6 mg/dL, bilirubin direct 8 mg/dL and hemoglobin 15 g/dL. An
ultrasound was performed for the patient and in it the gallbladder with
increased thickness (about 10 mm) and splenomegaly and lymph nodes with
dimensions of 14.5 * 11 and 8 mm were seen at the site of gastrohepatic
ligament and Porta Hepatis, respectively. Due to fever, jaundice,
abdominal pain and thrombocytopenia, and cervical lymphadenopathy,
possible diagnoses including acute viral hepatitis and AIH and Wilson
and hemochromatosis and viral infection with EBV, CMV, and HSV as well
as lymphoma were proposed. Related tests were requested based on these
differential diagnoses, and according to the submandibular
lymphadenopathy observed on the second day of cervical lymph node
ultrasound, in which a number of lymph nodes with a reactive view with a
maximum short-axis diameter of 6.6 and 6 mm, respectively, in the
right-side zone and with A maximum of 10 mm was seen in the
submandibular region and a maximum of 5.5 in the left of zone 2.
During the hospitalization process, the AST and ALT levels increased to
93 and 75, respectively, the white blood cell count also reached 7900,
and the platelet count decreased to 14,000 after an increase. On the
third day of hospitalization, jaundice and abdominal pain improved, but
the patient developed joint pain and tenderness in the joints, but no
active arthritis was seen, which led to the possibility of infectious
processes such as hepatitis and lupus. ANA and viral marker tests were
performed to check them. The results of the patient tests showed that
the patient was infected with Epstein-Barr virus due to a positive VCA
test and a high EBV IgM antibody titer, and the results of other patient
tests were negative. Abdominal and pelvic CT performed on the fourth day
of mild pleural effusion hospitalization with lung collapse in the right
hemithorax as well as splenomegaly, hepatomegaly, and multiple
lymphadenopathies in the mesenteric area of the celiac region and with
maximum size were observed, which are cases of non-Hodgkin’s lymphoma,
and due to this possibility and the decrease in the patient’s platelets
from 65,000 to 14,000, a BMA patient was performed, which was a dry tap,
followed by a biopsy, which was based on the biopsy result and the
observation of fragmented and crushed bone trabeculae with the scattered
and small crushed nest of marrow cells on the fibrotic background, which
appeared to be mainly small lymphocytes that make the possibility of
lymphoma increased and a request for immunohistochemistry was made, but
unfortunately, the patient was expired. (Figure 1)