Detailed Treatment Process
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Male, 20 years old, self-reported symptoms including elevated temperature, enlarged lymph nodes in multiple areas, persisting for several months. He had visited at least five major hospitals across three cities. First year October 17, cervical ultrasound showed multiple enlarged lymph nodes on the left side of the neck. First year October 18, cervical lymph node fine-needle aspiration cytology report as follows: Report type: Cytological pathology diagnosis report Gender: Male Age: 20 years Specimen submission date: First year October 18 Specimen: Left neck mass puncture Opinion and diagnosis Left cervical lymph node FNAC: Mature lymphocytes and transformed lymphocytes are present. No obvious cellular atypia is seen. These findings are consistent with reactive lymphoid hyperplasia. Report date: October 19 of the first year On October 24 of the first year, colonoscopy report as follows: Report: Painless electronic colonoscopy diagnostic report Examination date: October 24 of the first year Department: Gastroenterology Symptoms: None listed 2. Endoscopic findings Bowel preparation was good. The colonoscope reached the terminal ileum. Terminal ileum: No abnormalities. Ileocecal valve: Lip-shaped. Appendiceal orifice: Arc-shaped. Ileocecal region: No abnormalities. Ascending colon: No abnormalities. Hepatic flexure: No abnormalities. Transverse colon: No abnormalities. Splenic flexure: No abnormalities. Descending colon: No abnormalities. Sigmoid colon: No abnormalities. Rectum: Mucosal congestion and edema. 3. Conclusions and recommendations Conclusion: Proctitis. Pathology: (blank) Biopsy sites: (blank) Recommendation: Follow-up after treatment. Gastroscopy (date unknown) showed chronic atrophic pangastritis with erosion and bile reflux. On November 2 of the first year, histological pathology report of left neck mass puncture as follows: Report: Histopathology diagnostic report Sex: Male Age: 20 years Submission date: November 2 of the first year Clinical diagnosis: Left cervical lymphadenopathy Specimen: Left neck II. Gross description One lymph node, 1 cm in diameter, bisected. Microscopic findings (two slides, both labeled: HE staining, 10X) III. Microscopic description and diagnosis One left cervical lymph node with focal paracortical hyperplasia containing small sheets of large cells. Recommend immunohistochemical staining for CD30, CD45RO, CD3, CD20, CD15, EMA, EBER, and T-cell/B-cell gene rearrangement studies for further evaluation. Report date: November 7 of the first year Nasopharyngoscopy (date unknown) showed no obvious abnormalities in the nasopharynx and chronic pharyngolaryngitis. On November 16 of the first year, IG/TCR gene rearrangement clonality analysis report as follows: Department: Pathology Report: IG and TCR gene rearrangement clonality analysis Sex: Male Age: 20 years Application date: November 11 of the first year Tests: IGH, IGK, TCRG rearrangement clonality analysis Method 1. Genomic DNA extracted from the submitted specimen. 2. Clonality analysis of IGH, IGK, and TCRG rearrangements performed according to the European BIOMED-2 protocol. Results: IGH(27) negative; IGK(13) negative; TCRG(5) negative. Specimen DNA quality: Visible 400 bp band. Positive control: Clear bands at target positions. Negative control: Negative. Conclusion: No clonal IGH, IGK, or TCRG gene rearrangements detected in the submitted specimen. Note: Interpret results in conjunction with morphology, immunophenotype, and clinical findings. Report date: November 16 of the first year On December 12 of the first year, tuberculosis antibody IgG was weakly positive, IgM negative. Syphilis, HIV, and HCV serology were unremarkable. On January 3 of the second year, ultrasound showed mildly enlarged bilateral inguinal and cervical lymph nodes. On January 23 of the second year, 64-slice CT of the oropharynx (plain scan with 3D reconstruction) report as follows: Radiology Department CT report Examination date: January 23 of the second year, 16:58:45 Sex: Male, Age: 20 years Department: Oral and Maxillofacial Surgery Region examined: 64-slice CT oropharynx plain scan (3D) Imaging findings: No definite mass or abnormal density in the hard palate. No obvious abnormalities in the maxilla or mandible. Several small lymph nodes visible in bilateral neck soft tissues. A cystic, slightly low-density lesion approximately 0.9 cm in size protrudes into the left maxillary sinus from the superior wall mucosa. Impression: 1. No definite occupying lesion in the hard palate on CT; further evaluation recommended. 2. Cystic lesion beneath the mucosa of the left maxillary sinus, likely a mucosal cyst. 3. Small bilateral cervical lymph nodes. Report date: January 23 of the second year, 17:01:06 On February 5 of the second year, antinuclear antibody panel (including anti-nucleosome, anti-Sm, anti-PO, anti-histone, anti-U1-snRNP, anti-SSA/Ro60, anti-SSA/Ro52, anti-SSB/La, anti-Scl-70, anti-centromere, anti-Jo-1, and anti-dsDNA antibodies) was negative. On February 5 of the second year: IgA 1.75 g/L, IgG 16.40 g/L, IgM 0.83 g/L, C3 583 mg/L, C4 132 mg/L, rheumatoid factor <20 IU/mL. On February 5 of the second year: TSH 6.96 mIU/L, FT3 5.12 pmol/L, FT4 10.48 pmol/L. On February 5 of the second year: Erythrocyte sedimentation rate 2 mm/h. On February 6 of the second year, blood culture showed no bacterial growth after five days. On February 6 of the second year, CT showed mildly enlarged bilateral axillary lymph nodes. On February 6 of the second year, antistreptolysin O titer 56.4 IU/mL. On February 7 of the second year, thyroid ultrasound was normal. On February 23 of the second year, complete blood count as follows: Age: 20 years, Sex: Male, Department: Gastroenterology Report time: February 23 of the second year WBC 6.82 × 10⁹/L Lymphocyte % 19.6% Monocyte % 7.9% Neutrophil % 71.8% Eosinophil % 0.4% Basophil % 0.3% Lymphocyte # 1.34 × 10⁹/L Monocyte # 0.54 × 10⁹/L Neutrophil # 4.90 × 10⁹/L Eosinophil # 0.03 × 10⁹/L Basophil # 0.02 × 10⁹/L RBC 5.23 × 10¹²/L HGB 164 g/L HCT 46.5% MCV 88.9 fL MCH 31.4 pg MCHC 353 g/L RDW 11.7% PLT 245 × 10⁹/L PCT 0.25 fL MPV 10.2 fL PDW 11.5 fL CRP 6.3 mg/L On February 23 of the second year, fecal occult blood test showed weakly positive transferrin; other parameters normal. On February 24 of the second year, PET-CT showed: 1. Thickened wall of the ascending colon with increased FDG uptake; multiple mildly enlarged lymph nodes around the ileocecal region with mild FDG uptake—most likely inflammatory. Diffuse linear FDG uptake in the colon, consistent with inflammation. Symmetric diffuse FDG uptake in bilateral tonsils, likely inflammatory; ENT follow-up recommended. No other obvious FDG-avid lesions in the whole body (including brain). 2. Left maxillary sinus cyst. 3. Mild diffuse increased FDG uptake in bone marrow within the scan range, likely reactive hyperplasia. After the author specifically instructed the patient to have a physician perform physical palpation of the lymph nodes, on February 28 of the second year an outpatient note stated: No obvious enlarged lymph nodes in bilateral neck or inguinal regions. Physical examination otherwise unremarkable. Recommend gastroenterology follow-up. At this point, the patient informed the author that all temperature readings were self-measured with an axillary thermometer and provided his recorded data (dozens of entries). Values generally did not exceed 37.4°C, most were below 37.2°C, and many were 37.0°C or lower. On March 14 of the second year, electronic gastroscopy showed chronic non-atrophic pangastritis. In March of the second year, colonoscopy indicated chronic inflammatory changes in the colonic mucosa. On March 14 of the second year, histological pathology report of intestinal biopsies as follows: Histopathology diagnostic report Sex: Male, Age: 20 years Department: Internal Medicine Submission date: March 14 of the second year Clinical diagnosis: Chronic inflammatory changes of colonic mucosa Specimens: Ileocecal region, transverse colon, sigmoid colon, rectum, ascending colon Gross and stereomicroscopic findings: Multiple small gray-white tissue fragments. Microscopic findings (HE 10X) Diagnosis: 1. Moderate chronic inflammation of ileocecal mucosa; glands uniform and regular; no fissuring ulcers, granulomas, or crypt abscesses. 2. Moderate chronic inflammation of transverse colon mucosa; glands uniform and regular; no fissuring ulcers, granulomas, or crypt abscesses. 3. Moderate chronic inflammation of sigmoid colon mucosa; glands uniform and regular; no fissuring ulcers, granulomas, or crypt abscesses. 4. Moderate chronic inflammation of rectal mucosa; glands uniform and regular; no fissuring ulcers, granulomas, or crypt abscesses. 5. Severe chronic inflammation with erosion of ascending colon mucosa; glands uniform and regular; no fissuring ulcers, granulomas, or crypt abscesses. Report date: March 15 of the second year At this stage, the author asked the family why such a young patient would have diffuse intestinal inflammation. The family then recalled that two years earlier, after a high-school graduation celebration and classmate gathering, the patient developed diarrhea and was hospitalized for one week. It appears the acute enteritis at that time became chronic and persisted until now. Over more than four months, the patient visited at least five major hospitals in three cities. The final clarification was: first, no enlarged lymph nodes; second, no fever; third, chronic intestinal inflammation causing occult blood in stool, which required treatment.