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Media stinal lymphadenopathy - tuberculosis or lymphoma?

67 years,old male with history of loss of appetite since,last 3 months- On examination- Pallor + , right cervical lymph node mass , Hb - 5.4 after 2 units of blood transfusion. Earlier 10 days,back Hb was 4.2 gm% . ESR - 142 X- RAY CHEST COPD changes and bilateral minimal pleural effusion. F.N.AC of neck lymph node mass only shows narcotic material- AFB staining negative. ULTRASOUND ABDOMEN- Normal except.mild splenomegaly . CECT chest - Bilateral pleural effusion with basal atelectasis .Significantly heterogenously enhancing medistinal lymphadenopathy . Considering medistinal lymphadenopathy and significantly raised ESR - 142 . Two possibilities are there 1.Tuberculosis 2.Lymphoma - could be DLBCL Considering the Lockdown- patient was investigated in private set up - what next to differentiate between tuberculosis or lymphoma. Empirically, I have started ATT . Only good centers can do CT guided medistinal lymph node biopsy - to rule out Lymphoma .Do bone marrow examination have a role . Even s.protein electrophoresis was done to rule out multiple myeloma which was normal

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I agree with your opinion of tuberculosis and to start on ATT Fnac is not suggestive specifically Bone marrow is not much helpful in lymphomas Only confirmation is by biopsy and that is too ct guided which you said not possible bcz of lockdown There is secondary infection as leucocytosis As hrct suggest pleural effusion b/l if it is possible for dignostic tapping it will be helpful Rest tt cbnaat etc may be completed
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I agree with your opinion of tuberculosis and to start on ATT Fnac is not suggestive specifically Bone marrow is not much helpful in lymphomas Only confirmation is by biopsy and that is too ct guided which you said not possible bcz of lockdown There is secondary infection as leucocytosis As hrct suggest pleural effusion b/l if it is possible for dignostic tapping it will be helpful Rest tt cbnaat etc may be completed
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Kindly follow CT guided biopsy of mediastinal lymphnode Cervical LN biopsy HB electrophoresis BMA Find the cause of anemia first Treat superadded infection Do TB GENEX from pleural fluid To rull out kochs
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3 approach.. I. Repeat fnac... for cytologic reevaluation... and for cbnaat. 2.excision bx of cervical lymph node for hpe and cbnaat... put tissue in n. saline. 3.tb igra from blood.
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If Bone Marrow infiltration by Lymphoma it is useful for diagnosis. And by bone marrow biopsy- IHC study is helpful for categorisation of Lymphoma.
Guided fnac/Bx of Mediastinal LN & BMBx for typing & staging of Lymphoma & CB NAAT & AFB to r/o TB.
Mostly Koch's do broncoscopic biopsy HP effusion tapping cbnat r/0 lyumphoma anaemia
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Biopsy of lymphnode is must for final diagnosis and treatment
Start ATT category 1 at least for 9 months.
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