A 14 years old boy was operated for a past history of tonsillitis with exceptionally enlarged tonsils. Tonsilectomy was done by dissection and snare method on 8-12-2009. He was relatively asymptomatic after tonsillectomy. Cytological test of the dissected tonsil mass revealed no malignancy. Prior to tonsillectomy CBC and LFT test were normal except an elevated level of Alkaline Phosphatase level of 470.0 U/L as against the normal range of 39-117 U/L as on 5-12-2009. The Ultrasound Abdoment revealed no abnormality on 9-12-2009, i.e a day after tonsillectomy and the patient was discharged from the hospital in stable condition with usual prescription of antiobiotic augmentin-625 etc.
A Contrast CT Scan Test of Chest and whiole abdomen conducted on 20th December, 2009, revealed few linear fibrotic reticulations scattered in upper (Apio Posterior Segments), Middle including the Lingula. The Study revealed a focal well defined lobulated soft tissue density lesion in the anterior Mediastinum with the Thymus Gland not decerned separate and measuring approx 24.6x22.5 mm in size. Bilateral axillary lymphnodes are also seen. Rest of bilateral lungs reveals normal parenchyma with normal broncho vascular pattern.
It also revealed multiple discrete non necrotic precarnial, sub carnial (size 11.5 mm) and tracheo-bronchial and hilar (size 5-8.0 mm) lymph nodes.
There were few peri pancreatic , gastro-hepatic and retro-mesenteric and mesenteric (largest 17.8 mm), retro-peritonial (largest 4.5 mm) including Iliac and Inguinal lymphadenopathy seen. Liver is borderline enlarged in size and contour and shows heterogenous parenchymal enhancement with peri portal collar of edema. Spleen is borderline enlarged in size and shows variegated texture. There are enlarged splenunuclie seen. All other abdomen findings were normal.
The patient developed fever and cough and was again admitted in hospital 22nd December, 2009 for further management and investigation. Routine investigation were done including CBC, PTT, Serum Calcium and Serum Phosphorus which were found normal. The Parathyroid Hormone (Intact) was abnormal at 304.3 on 20-12 2009 indicationg Hyper parathyroidism. Blood culture revealed no growth. CT guided FNAC could not be performed as the lobulated soft tissue density lesion in the anterior mediastinum with thymus gland was not possible to approach due to its proximity with heart on one side and blockade by a bone on the other side. CT guided FNAC and biopsy was also not performed as no significant abdominal and chest nodal mass was available to the technician. Due to this Bone marro aspiration and biopsy and parathyroid scan was performed on 24-12-2009 which also revealed a normal study. An Oncologist has recommended for a PET Scan which could not be performed til date due to low Total Leucocyte Count (TLC) of the patient.
The patient is now under observation and it is noted that his Total Leucocyte Count has been deteriorating since tonsillectomy on 8-12-2009. The TLC was above 8000 prior to 8-12-2009 (tonsillectomy) which came down to 6700 on 19-12-2009, 6600 on 22-12-2009, 4100 on 26-12-2009 and further down to 4000 on 31-12-2009.
The patient have no other problem at present except some weakness.
Are above finding consistent with any serious malignant or benign disorder? What further investigation and treatment is necessary in above case? Is it safe to perform PET test when Total Leucocyte Count (TLC) level is progressively coming down since tonsillectomy?
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