Chronic hepatitis B and liver cirrhosis, major findings in physical examination... | Case actual combat

Author: Zhang Xiaoyan, Shao Ming, Xiao Yuzhen, Hepatobiliary and Stomach Disease Specialist Hospital, Yongji City, Shanxi Province.
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Case data Patient Ding, male, 61 years old, from Shanxi.

Mainly because of "20 years of chronic hepatitis B, fatigue and abdominal distension for 1 month", he was admitted to our hospital on February 22, 2019.

History of present illness: Chronic hepatitis B was detected during physical examination 20 years ago, but no regular review and standardized treatment were performed.

Feeling fatigue, abdominal distension, weight loss 1 month ago, weight loss of 5 kg within 1 month, no fever, no chills, no nausea, no vomiting symptoms, go to a hospital, color Doppler ultrasound showed: liver cirrhosis, gallbladder wall thickness, double splenomegaly and ascites He was treated with oral spironolactone tablets and was diagnosed as "cirrhotic chronic hepatitis B".
He was hospitalized for 1 week and the effect was not good.
For further diagnosis and treatment, he came to our hospital for treatment.

The patient’s spirit was poor at this time, his diet was 1/3 less than normal, his night sleep was poor, his stool was normal; his urine was yellow and his volume was normal.

Epidemiological history: denied history of blood transfusion and blood products, history of vaccination is unknown.

Past history: Deny the history of hypertension, heart disease, diabetes, and deny the history of trauma.

Deny the history of infectious diseases such as typhoid fever and tuberculosis, deny the history of poisoning, and deny the history of drug allergy.

Personal history: Born locally, never been to an epidemic area, smoking and drinking a little.

Marriage and childbirth history: married at the age of 23.

He has 1 son and 2 daughters, and his spouse and children are in good health.

Family history: His mother, sister, and younger brother all suffered from hepatitis B and cirrhosis and died.

Physical examination temperature: 36.
3℃ Pulse: 54 beats/minute Breathing: 19 beats/minute Blood pressure: 110/60mmHg Weight: 50Kg Skin and sclera have mild yellowing, no spider moles and liver palms are seen.No palpable swelling of the thyroid gland on both sides.

Submental, submandibular, and neck palpable 2.
0X2.
0cm enlarged lymph nodes, medium in quality, smooth surface, no adhesion to adjacent tissues, no tenderness.

5X5cm swollen lymph nodes can be palpable on the left upper side of the clavicle, right under the axilla, and right inguinal area, hard, smooth surface, movable, and no tenderness; 3X2.
5cm swollen lymph nodes can be palpable under the left axilla and left inguinal area, Hard, smooth surface, movable, no tenderness.

Breath sounds in both lungs were clear, and no dry and wet rales were heard.

The heart rate was 54 beats/min, the heart rhythm was uniform, and no murmur was heard in the auscultation area of ​​each valve.

The abdomen is full, without limited bulging, varicose veins and gastrointestinal peristaltic waves.

Upper abdominal tenderness (+), rebound pain (-), Murphy sign (-), no umbilical hernia.

The liver under the ribs is not palpable, and the spleen is palpable at 5 cm under the ribs.
The texture is tough, the surface is smooth, tender (-), and fluid wave tremor (-).

Mobile dullness (-), percussive pain in the liver area (+).

Bowel sounds 5 times/min, and pitting edema of both lower limbs (+).

                                    2019-02-21 Outer hospital inspection results: liver function: TB: 51.
9 µmol/L, DB: 29.
3 µmol/L, IB: 22.
6 µmol/L, ALT: 34.
0U/L, AST: 50.
0U/L, Alb: 28.
0 g/L.

Abdominal color Doppler ultrasound showed: liver cirrhosis and splenomegaly secondary gallbladder changes.

Preliminary diagnosis: 1.
Decompensated liver cirrhosis 2.
Hypoproteinemia 3.
Chronic viral hepatitis (type B) 4.
Lymph node enlargement causes undiagnosed lymphoma? Giant lymphadenopathy? Examination results after admission: liver function TB: 64.
0 µmol/L, DB: 45.
0 µmol/L, IB: 19.
0 µmol/L, ALT: 95.
0U/L, AST: 112.
0U/L, ALP: 51.
2U/L, GGT :33.
0U/L, ChE: 3833.
1U/L, LDH: 153.
0U/L, AFU: 25.
1U/L, TP: 64.
7g/L, Alb: 28.
4g/L, Glo: 36.
3g/L, PA: 86.
0mg/L; TBA: 85.
0μmol/L; Glu: 4.
7mmol/L; 8 items of blood lipids: normal; 4 items of renal function: normal; 7 items of electrolyte: Na: 136.
5mmol/L, remaining normal; HCY: 15.
7μmol /L; CRP: 12.
0mg/L; CK: 68.
9U/L, CK-MB: 7.
8 U/L; anti-HAV-IgM, anti-HCV, anti-HDV, anti-HEV, anti-HGV, anti-HIV, RPR: negative; Hepatitis B series: HBsAg (+), anti-HBs (-), HBeAg (-), anti-HBe (+), anti-HBc (+), anti-HBc-IgM (-).

Blood type: type B, Rh (D): positive; blood routine: WBC: 2.
13×109/L, RBC: 4.
17×1012/L, HGB: 130.
0g/L, PLT: 88.
0×109/L; coagulation set: PT : 14.
28 (Sec), INR: 1.
24, remaining normal; Thyroid function: normal; AFP: 5.
58 IU/ml; CEA: 2.
61 ng/ml; CA-125: 12.
06 U/ ml; CA-199: 8.
29 U/ ml; PCR: HBV-DNA quantitative: 2.
0×104IU/ml; liver fiber series: HA: 95.
38ng/ml, CG: 15.
28ug/ml, the rest is normal; Epstein-Barr virus (EB-DNA) quantitative: <5.
00E+03.

Serum copper, serum iron, ceruloplasmin: normal.

8 autoimmune liver disease antibodies: negative.

Immunoglobulins IgM, IgG, IgA: normal.

Urine 11 items: bilirubin: (+), urobilinogen: (+), the rest is normal.

Then RT: (-), OB: (-).

Electrocardiogram: normal electrocardiogram; chest radiograph: high-density shadow in the lower right lung field (consider consolidation), aortic sclerosis, right axillary space-occupying disease, chest CT examination is recommended.

Abdominal color Doppler ultrasound showed: 1.
Liver cirrhosis and splenomegaly without ascites 2.
Abdominal enlargement of lymph nodes (2.
6X1.
4cm) 3.
Secondary gallbladder changes.

Chest CT scan showed: space-occupying lesions in the lateral basal segment of the right lower lobe (consider squamous cell carcinoma) and enlarged axillary and anterior upper mediastinum lymph nodes (consider lymphoma).

CT of the upper abdomen showed liver cirrhosis, splenomegaly, and lower esophageal varicose veins.

Figure 1 Enlarged lymph nodes in the neck protruding from the skin Figure 2 Enlarged lymph nodes in the right armpit Figure 3 Enlarged lymph nodes in the right inguinal region Figure 4 Take a biopsy of lymph nodes in patients with chronic hepatitis B and liver cirrhosis, which are common clinically, and this patient has multiple lymph nodes swollen , And the lymph node volume is large, the patient is thinner, and the clinically found lymph node enlargement needs to be differentiated from the following diseases: 1.
Tuberculous lymphadenitis: often associated with tuberculosis, OT test is positive, local lesions may sometimes show limited fluctuations or ulceration , Anti-tuberculosis treatment is effective.

2.
Acute and chronic lymphocytic leukemia: common systemic superficial lymph nodes are enlarged, hard, non-tender, non-adhesive, and often hepatosplenomegaly; bone marrow aspiration and lymph node biopsy show leukemia changes.

3.
Eosinophilic lymphogranuloma: Some patients have multiple superficial lymphadenopathy, which resembles malignant lymphoma in clinic, respond well to radiation or chemotherapy, and have a good prognosis.

Such patients may sometimes have bilateral parotid gland enlargement, an increase in the number of eosinophils in the blood, and obvious pathological characteristics.

4.
Giant lymphadenopathy: a rare lymphadenopathy between benign and malignant.

The cause is unknown, it may be a local or systemic infection.
Inflammation, with the participation of neurohumoral factors, stimulates the proliferation of lymph nodes. Due to the difference in antibody reactivity, the main pathological feature is significant vascular proliferation and hyaline change or with increased plasma cells.

Generally divided into three types, namely plasma cell type, hyaline vascular type and intermediate type.

In order to further confirm the diagnosis on February 24, 2019, the right inguinal lymph nodes were removed under local infiltration anesthesia at 10:00.
Three enlarged lymph nodes of 5cmX4cm, 4cmX3cm, and 3cmX2cm were taken out and sent for pathological examination.
The operation process went smoothly.

Pathological analysis report on the 27th: The light microscope findings are as follows: Figure 5 The pathological examination light microscope findings Diagnosis description: the structure of the lymph nodes disappeared, the lymphocytes grew diffusely, the morphology was single, and the nuclei were deeply stained.

Diagnosis: non-Hodgkin's lymphoma.

The patient did not do immunohistochemistry due to economic reasons.

Final diagnosis 1.
Non-Hodgkin’s lymphoma 2.
Lung mass 3.
Decompensated liver cirrhosis 4.
Hypoproteinemia 5.
Hypersplenism 6.
Viral hepatitis (type B) chronic follow-up, and standard treatment is recommended.
The patient will not be considered due to economic reasons.

After discharge from the hospital, entecavir tablets were taken orally and oxycodone hydrochloride sustained-release tablets were taken intermittently to support symptomatic treatment.
The patient died six months later.

Discussion Lymph nodes are one of the most important immune organs in the human body.
Normal people have about 500-600 lymph nodes.
They are the place where the immune response is stimulated by antigens, and they have the functions of filtering, proliferation and immunity.

Normal human superficial lymph nodes are very small, mostly within 0.
5cm in diameter, with smooth and soft surface, no adhesion to surrounding tissues, and no tenderness.

Lymph node enlargement refers to the inflammation of the lymph nodes in the submandibular, armpit, groin, etc.
, which are swollen due to the stimulation of bacteria and their toxins and can be obviously touched by hands, often accompanied by painful symptoms.

There are many causes of its disease.
When an infection occurs in a certain part of the body, when the bacteria pass through the lymph node with the lymph fluid, it can correspondingly cause the swelling and pain of the lymph node group.

When the body suffers from malignant tumors, it often metastasizes along the lymphatic vessels and stays in the lymph nodes to divide and proliferate, resulting in swelling of the lymph nodes.

Lymph node enlargement is very common and can occur in people of any age.
It can be seen in a variety of diseases, benign and malignant.
Therefore, it is very important to pay attention to the causes of lymph node enlargement and seek medical treatment and diagnosis in time to avoid misdiagnosis or missed diagnosis.

In recent years, lymphoma has been increasing year by year, and the incidence rate of men is significantly higher than that of women.

The mortality rate of lymphoma in my country is 1.
5 per 100,000, ranking 11th to 13th among malignant tumor deaths.

Hodgkin's lymphoma (HL) accounts for only 8% to 11% of lymphomas.

From 1950 to 1990, the mortality rate of non-Hodgkin's lymphoma (NHL) in the world increased by 1.
5 times, which may be related to the deterioration of the environment, the extension of life span, and the progress of histopathological diagnosis.

NHL often primarily involves extranodal lymphatic tissues, and often spreads in jumps, and metastasizes to distant lymph nodes across adjacent lymph nodes.

Most NHLs are aggressive, develop rapidly, and are prone to early distant spread.

NHL can occur in any part of the body, showing different clinical symptoms, with certain differences.

This patient was found to have obvious swelling of the lymph nodes throughout the body, and spread to a wide range.

The clinical manifestations of NHL have the following characteristics: 1.
The incidence increases with age, with more males than females; 2.
NHL has a tendency to spread distantly and extranodal invasion, and it is more common than HL to infringe on various organs; 3.
High fever or symptoms of various systems, painless neck and supraclavicular lymph node progressive enlargement as the first manifestation are fewer than HL; 4.
Except for indolent lymphoma, it generally develops rapidly.

Biopsy confirmed that about 1/4 to 1/2 of the patients had liver involvement, and splenomegaly was only seen in later cases.

Clinically, patients with chronic hepatitis B and liver cirrhosis are more common, and the medical history should be carefully asked and a systematic physical examination should be conducted.
Sometimes, the missed diagnosis or misdiagnosis can be caused by ignoring certain symptoms or signs.

Non-Hodgkin's lymphoma can invade the liver, with liver, splenomegaly and jaundice as common symptoms.

Therefore, for every patient who goes to the clinic, the clinician must perform a detailed physical examination.
The small lymph nodes are of great significance.
As a clinician, please pay attention to the lymph node examination!