What's the Diagnosis?

Hanumanthu 45/M
Presented with H/O

• Increasing difficulty in walking: 4 days
• Pain in the joints with associated swelling: 4 days

On further questioning:

• Progressive loss of weight: 4 months
• Anorexia: 4 months
• No h/o - Nausea/Vomiting/Haematemesis/Cough/Fever/Unusual swellings/Non healing ulcers.

Examination:

• Weight 39 kg Height 170 cm, Afebrile
• Pallor ++, Icterus +/-, Bilateral pitting oedema over the ankles, No lymphadenopathy/ Clubbing/ Skin changes
• Pulse 110/minute, BP 110/70 mm Hg

Systems:

ABDOMEN:

• Thin, Liver palpable 2.0 cm
• Spleen NP
• No evidence of free fluid

CNS:

• Gd III/V power both Upper as well as lower limbs
• DTJ: Sluggish
• Plantars: Flexor

CVS/RS: NAD

What's the suspicion?
How will you proceed - remember this is a primary care setting.

PART 2

Investigations:

Hb: 9.5 gm%, TC 6000/cumm, P 88 (Neutrophils show toxic granulations) L12, RBS 115 mg%

Urine: Albumin +++, Pus cells Numerous, RBCs 1-2, Epith Cells 2-4, Ca Oxalate crystals 8 - 10

X-Ray Chest PA: Hilar flare ? Para hilar and mediastinal nodes enlarged

The following tests ordered LFT , Blood Urea, Creatinine, HIV and HBSAg

Wow - now what - the picture gets more and more confusing:

So when in doubt - Started Cap Amoxycillin 500 mg tid along with B-complex

Part 3

The patient comes back after a couple of days:
No change except that the joint pains have reduced:

Investigations:

Total Bilirubin: 2.15 mg%, Direct 1.55, Indirect 0.60 ???

SGOT: 113 u/L, SGPT 24 u/L, Alk PO4ase 134 IU/L

Total Proteins 5.6 gm%, Albumin 3.4, Globulin 2.2, A:G Ratio 1:1.5

Urea 15 mg%, Creatinine 0.9%

HIV (Tridot) -ve HBSAg (Hepacard)-ve

On the basis of this a presumptive diagnosis of CA Head Pancreas was made - on clinical grounds

USG: Hepatomegaly with fatty changes, Large cystic lesion of Head of pancreas (?Infective etiology), Cystic lesion Anterior to Aorta - possibility of necrotic lymph node/Aneurysm

NOW WHAT - Patient has disappeared and we are trying to trace him.

Are we looking at a TB etiology???

Answers please