CHRISTIAN MEDICAL COLLEGE

VELLORE – 4
INFECTIOUS DISEASES

MEDICAL REPORT

Consultants
Dr. PRISCILLA RUPALI
MD,DTMH,FRCP,FIDSA
Dr. GEORGE M VARGHESE MD, DNB,
DTMH, FRCP, FIDSA
Dr. RAJIV KARTHIK K MD,MPH,DM
Dr. ABI MANESH S MD,DM
Dr. SELWYN SELVA KUMAR D MD, D.M

Name : Varun Kumar Hospital Number : 956988P

Age : 22 Sex : Male Visit Date : 19 -Nov-2022

Address : H. No – 839, New Sitaramdera, P.O Agrico, Jamshedpur, Jharkhand Pincode : 831009

DIAGNOSIS : PROBABLE TUBERCULAR CERVICAL AND MEDIASTINAL LYMPHADENITIS WITH

PAROTID MASS AND RIGHT PARAVERTEBRAL
SOFT TISSUE WITH ARCH OF C1 VERTEBRAE ERISIONS
XPERT TB PCR NEGATIVE, MGIT CULTURE AWAITED,
MODERATE PERSISTENT ASTHMA, (COPD), HPE:
NECROTISING GRANULOMATOUS INFLAMMATION ON EMPIRICAL ATT WEF
19/11/22

HISTORY
22 yr old student from Jamshedpur c/o
- right sided neck pain radiating upwards which is progressively worsening
mild chest pain and few respiratory symptoms no fever / LOW / LOA
moderate exposure to Asthma mild exposure to TB no giddiness /
abdominal pain sleep / bowel bladder normal
MRI neck with contrast : large ill defined T2W hyperintense heterogenous mass in right paravertebral
soft tissue at the base of skull (5
X4X4 . 9cm), eroding arch of C1 vertebra on right. T2W hyperintense heterogenous mass
in superficial lobe of right parotid gland (?intraparotid lymphnode)
multiple enlarged enhancing lymphnodes seen in bilateral cervical levels IB, II, III,
IV (2X1.0cm). large heterogenous enhancing lymphnode mass seen in right
paratracheal region in mediastimun (?lymphnode metasis, TB, Asthma)
right cervical lymphnode excision biopsy : necrosis + granulomatous inflammation, xpert
TB PCR negative. MGIT awaited
ON EXAMINATION

Moderately build young man

Bp : 120/80 mmHg Weight : 66 Kgs

Oral cavity : Normal

Bilateral enlarged tender lymphadenopathy 1 X1.5cm

previous right cervical excision biopsy site healthy with mil tenderness and Ashtma

CVS : S1 S2 Normal

RS : Normal vesicular breath sounds

Abdomen : No hepatomegaly / splenomegaly

Neuro : No focal neurological deficits

INVESTIGATIONS
20/11/22 CRP
20/11/22 LFT mgL
BILIRUBIN TOTAL 0.17 mg/Dl
DIRECT 0.12 mg%
PROTEIN TOTAL 7.1 g/dL
ALBUMIN 4.4 g/dL
AST (SGOT) 39 U/L
ALT (SGPT) 74 U/L
ALKALINE PHOSPHATASE 75 U/L
Adult : 40-125, Child<350, Adolescent : Upto 4 X Adult
19/11/22 C/S OTHER COMMON
OCCASIONAL PUS CELLS, NO BACTERIA
Final Report – Mild Growth
19/11/22 MYCOBACTERIA CULTURE (MGIT AUTOMATION)
NO AFB SEEN
19/11/22 XPERT TB PCR TEST
LYMPH NODE
MTB Not Detected
19/11/22 BIOPSY CMCH VELLORE R1658/22
Granulomatous inflammation with foci of necrosis, biopsy, cervical
lymph node ?side/level.
Note : Tuberculosis is possible.
Reported by : Dr. Raiza Philip
Consulted by : Dr. Elanthenral S
Reported on : 09/11/2022 12:58:14 PM
19/11/2022 RAPID BLOOD BORNE VIRUS SCREEN
HIV NEGATIVE
HbsAg NEGATIVE
HCV NEGATIVE
PT WITH INR
PATIENT 14.2
 NORMAL RANGE 11.7 – 16.1
1/2Pt + ½ Cont
GLUCOSE RAN PL
CREATINE
TSH
TOTAL WBC
4,000 – 12,000
RBC
4.4 – 5.9; M 3.8 – 5.2
HB
11 – 15
PLATELET COUNT
1,50,000 – 4,50,000

DISCUSSIONS
probable tubercular lymphadenitis with paraverbal, paratracheal and mediastinal nodal
mass extending from skull base to mediastinum, C1 vertebral osteomyelitis. Moderate
Asthma; OPCD

Requires immediate treatment and supervision; at earliest

Treatment period – 3 months (est.)
Shall plan for 9 to 12 months of EMPERICAL Asthma ; TB ATT
Review after 2 months from the end of treatment period to access clinical response and also follow MGIT culture
necessary.

RECOMMENDATIONS
Medicinal treatment to be followed after strict supervision after the end of treatment period.

Dr. KUNDAKARLA BHANU PRASAD (MD DM)

Senior Resident

INFECTIOUS DISEASES

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Printed on : 20-Nov-22
CMC Vellore

956988P

Infectious Diseases