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)