Detailed Treatment Process
Male, 20 years old, self-reported symptoms including elevated body temperature + enlarged lymph nodes in multiple sites throughout the body + symptoms persisting for several months, sought medical care in at least 5 major hospitals across three cities On October 17 of the first year, cervical ultrasound showed multiple enlarged lymph nodes in the left neck On October 18 of the first year, cervical lymph node puncture pathology report is as follows Report type: Cytological pathology diagnosis report Gender: Male Age: 20 years old Specimen submission date: October 18 of the first year Specimen: Left neck mass puncture Opinion and diagnosis Left cervical lymph node FNAC: Mature lymphocytes and transformed lymphocytes are visible, with no obvious atypia of the cells, considered as reactive hyperplasia of lymph nodes. Report date: October 19 of the first year
On October 24 of the first year, colonoscopy report is as follows Report name: Painless electronic colonoscopy diagnosis and treatment report Examination date: October 24 of the first year Department: Gastroenterology Symptoms: / 2. Examination findings Bowel preparation was good, and the colonoscope reached the terminal ileum Terminal ileum: No abnormality Ileocecal valve: Lip-shaped Appendiceal orifice: Arc-shaped Ileocecal region: No abnormality Ascending colon: No abnormality Hepatic flexure: No abnormality Transverse colon: No abnormality Splenic flexure: No abnormality Descending colon: No abnormality Sigmoid colon: No abnormality Rectum: Mucosal congestion and edema 3. Examination conclusions and recommendations Examination conclusion: Proctitis Pathological diagnosis: (blank) Biopsy site: (blank) Recommendation: Follow-up review after treatment
The gastroscopy conclusion on an unspecified date was chronic atrophic pangastritis with erosion and bile reflux On November 2 of the first year, left neck mass puncture pathology report is as follows Report name: Histopathological diagnosis report Gender: Male Age: 20 years old Specimen submission date: November 2 of the first year Clinical diagnosis: Left cervical lymph node enlargement Specimen: Left neck II. Examination description Gross findings (stereoscopic examination): One lymph node, 1 cm in diameter, cut open. Microscopic findings: (Including two pathological section images, both labeled: Stain: HE 10X) III. Microscopic description and pathological diagnosis (Left neck) One lymph node, with local paracortical hyperplasia and small patches of large cells seen inside. Recommend further testing with CD30, CD45RO, CD3, CD20, CD15, EMA, EBER, and T-cell and B-cell gene rearrangement studies in our department for definitive diagnosis. Report date: 2017-11-07
The nasopharyngoscopy conclusion on an unspecified date was no obvious abnormality in the nasopharynx and chronic pharyngolaryngitis The IG, TCR gene rearrangement clonality analysis report on November 16 of the first year is as follows Department: Pathology Report name: IG, TCR Gene Rearrangement Clonality Analysis Report Gender: Male Age: 20 years old Application time: November 11 of the first year Test items: IGH, IGK, TCRG rearrangement clonality analysis Test method 1. Extraction of genomic DNA from the submitted specimen 2. Analysis of IGH, IGK, TCRG rearrangement clonality in the specimen's genomic DNA using the European BIOMED-2 protocol Note: According to the latest HGNC naming rules, gene names are standardized as IGK instead of IGκ; TCRG instead of TCRγ, all in uppercase letters Test results: IGH(27) negative; IGK(13) negative; TCRG(5) negative Specimen DNA quality test: Visible 400bp band Positive control: Clear bands appear at the target positions Negative control: Negative Conclusion: IGH, IGK, TCRG clonal rearrangements in the submitted specimen are negative Note: This test result should be interpreted in conjunction with other morphological and immunological findings as well as clinical presentation Report time: November 16 of the first year
On December 12 of the first year, tuberculosis antibody IgG weakly positive, tuberculosis antibody IgM negative, syphilis spiral antibody test value normal, HIV antigen/antibody test value normal, hepatitis C virus antibody test value normal On January 3 of the second year, ultrasound showed slightly enlarged lymph nodes in bilateral inguinal regions and bilateral cervical regions On January 23 of the second year, 64-slice CT plain scan of the oropharynx (3D) report is as follows Guangxi Zhuang Autonomous Region People's Hospital Radiology Department CT Examination Report Examination date: January 23 of the second year 16:58:45 Gender: Male, Age: 20 years old Department: Oral and Maxillofacial Surgery Examination site: 64-slice CT oropharynx plain scan (3D) Imaging findings: No definite mass or abnormal density shadow in the palate. No obvious abnormal density shadows in the upper and lower jaws or bilateral maxillofacial regions. A cystic slightly low-density shadow is visible under the mucosa of the upper wall of the left maxillary sinus, protruding into the lumen, measuring approximately 0.9 cm. Several small lymph nodes are visible in the bilateral cervical soft tissues. Impression: 1. No definite occupying lesion on palatal CT plain scan; further examination is recommended. 2. Cystic slightly low-density shadow under the mucosa of the left maxillary sinus, considered a submucosal cyst. 3. Small lymph nodes visible in bilateral neck. Report date: January 23 of the second year 17:01:06
On February 5 of the second year, laboratory tests showed normal values for antinuclear antibody, anti-nucleosome antibody, anti-Sm antibody, anti-PO antibody, anti-histone antibody, anti-U1-snRNP antibody, anti-SSA/RO60KD antibody, anti-SSA/RO52KD antibody, anti-SSB/La antibody, anti-Scl-70 antibody, anti-centromere antibody, anti-Jo-1 antibody, and anti-double-stranded DNA antibody On February 5 of the second year, laboratory tests: immunoglobulin A = 1.75, immunoglobulin G = 16.40, immunoglobulin M = 0.83, complement C3 = 583, complement C4 = 132, rheumatoid factor < 20 On February 5 of the second year, laboratory tests: thyroid-stimulating hormone 6.96, FT3 5.12, FT4 10.48 On February 5 of the second year, laboratory tests: erythrocyte sedimentation rate 2 On February 6 of the second year, blood culture + drug sensitivity test results: no bacterial growth after 5 days of culture On February 6 of the second year, CT showed slightly enlarged lymph node shadows in bilateral axillae On February 6 of the second year, laboratory tests: antistreptolysin O test value 56.4 On February 7 of the second year, thyroid color ultrasound showed no abnormality in thyroid morphology On February 23 of the second year, routine blood test report is as follows Age: 20 years old Gender: Male Department: Gastroenterology Report time: February 23 of the second year WBC white blood cell count 6.82 × 10⁹/L LY lymphocyte percentage 19.6% MO monocyte percentage 7.9% NE neutrophil percentage 71.8% EO eosinophil percentage 0.4% BA basophil percentage 0.3% LY# lymphocyte count 1.34 × 10⁹/L MO# monocyte count 0.54 × 10⁹/L NE# neutrophil count 4.90 × 10⁹/L EO# eosinophil count 0.03 × 10⁹/L BA# basophil count 0.02 × 10⁹/L RBC red blood cell count 5.23 × 10¹²/L HGB hemoglobin 164 g/L HCT hematocrit 46.5% MCV mean corpuscular volume 88.9 fL MCH mean corpuscular hemoglobin 31.4 pg MCHC mean corpuscular hemoglobin concentration 353 g/L RDW red blood cell distribution width 11.7% PLT platelet count 245 × 10⁹/L PCT plateletcrit 0.25 fL MPV mean platelet volume 10.2 fL PDW platelet distribution width 11.5 fL KCRP C-reactive protein 6.3 mg/L
On February 23 of the second year, stool test showed weakly positive transferrin, with no abnormalities in other items On February 24 of the second year, PET-CT examination report showed: 1. Thickened wall of the ascending colon with increased FDG uptake, multiple slightly enlarged lymph nodes around the ileocecal region with mild increased FDG uptake, inflammatory lesion more likely, colonoscopy recommended; diffuse striped increased FDG uptake in the colon, considered inflammatory lesion; diffuse symmetric increased FDG uptake in bilateral tonsils, considered inflammatory changes, ENT follow-up recommended; no obvious abnormal increased FDG uptake foci elsewhere in the whole body (including brain) on PET imaging. 2. Left maxillary sinus cyst. 3. Mild diffuse increased FDG uptake in the bone marrow within the scan range, considered hyperplastic changes
* After the author specifically instructed that the doctor must perform palpation of the lymph nodes, on February 28 of the second year, an outpatient doctor handwrote in the medical record: No obvious enlarged lymph nodes in bilateral neck, inguinal regions, and other areas; PE: general condition fair, recommend gastroenterology follow-up At this time, the patient told the author that all temperatures were measured by himself using an axillary thermometer and sent his recorded temperature data (estimated dozens of entries). Most did not exceed 37.4°C, mostly below 37.2°C, and many were not higher than 37.0°C. On March 14 of the second year, electronic gastroscopy showed chronic non-atrophic pangastritis In March of the second year, colonoscopy report showed chronic inflammatory changes in the large intestinal mucosa On March 14 of the second year, colonoscopy histological pathology report is as follows Histopathological diagnosis report Gender: Male Age: 20 years old Requesting department: Internal medicine Specimen submission date: March 14 of the second year Clinical diagnosis: Chronic inflammatory changes in large intestinal mucosa Specimen: Ileocecal region, transverse colon, sigmoid colon, rectum, ascending colon Gross findings and stereoscopic examination: 1. Gray-white tissue 2 points, maximum diameter 0.2-0.4 cm 2. Gray-white tissue 2 points, maximum diameter 0.1-0.3 cm 3. Gray-white tissue 2 points, maximum diameter 0.2-0.4 cm 4. Gray-white tissue 2 points, maximum diameter 0.1-0.4 cm 5. Gray-white tissue 2 points, maximum diameter 0.3-0.5 cm Microscopic findings Stain HE 10X; Stain HE 10X Microscopic description and pathological diagnosis 1. Moderate chronic inflammation of the ileocecal mucosa, glands evenly distributed with regular shape, no fissure-like ulcers, granulomas, or crypt abscesses 2. Moderate chronic inflammation of the transverse colon mucosa, glands evenly distributed with regular shape, no fissure-like ulcers, granulomas, or crypt abscesses 3. Moderate chronic inflammation of the sigmoid colon mucosa, glands evenly distributed with regular shape, no fissure-like ulcers, granulomas, or crypt abscesses 4. Moderate chronic inflammation of the rectal mucosa, glands evenly distributed with regular shape, no fissure-like ulcers, granulomas, or crypt abscesses 5. Severe chronic inflammation with erosion of the ascending colon mucosa, glands evenly distributed with regular shape, no fissure-like ulcers, granulomas, or crypt abscesses Report date: March 15 of the second year At this point, the author asked the family: Why would someone so young have diffuse intestinal inflammation? The family then recalled that two years earlier, after a classmate gathering to celebrate high school graduation, the patient had diarrhea and was hospitalized for a week. It was estimated that the intestinal inflammation from that time had become chronic and persisted until now. This matter lasted more than 4 months, with visits to at least 5 major hospitals across three cities. It was finally clarified: first, there were no enlarged lymph nodes; second, there was no fever; third, chronic intestinal inflammation causing fecal occult blood, which required treatment.