Apr 30, 2015
Newsletter Vol 6 iss 2 May 2015
It is summer but with severe rainfall as well! We will have less mangoes due to the natural calamity. We at lotus had a lot of activity lately as my younger brother Dr Saket Junagade who is an interventional cardiologist trained in panerai replica watches UK and Singapore has joined us. The case I am going to present today hopefully will have a lot of take home messages, which is the main intention of this newsletter.
Case 1: 27 year old female doctor complained of abdominal pain and fever for 5-7 days. No history of obvious swelling. She had occasional joint pain but not severe. She got herself investigated and USG showed some lymphadenopathy in abdomen. CT scan was done and the mesenteric lymphadenopathy was confirmed. The size was maximum1.5- 2.0cm. They consulted an oncosurgeon and they decided to do biopsy, hence a laparoscopic biopsy was done and sent to Mumbai for histopathology. The report was Hodgkin’s Lymphoma (indeterminate type). The family panicked as expected. Oncosurgeon started chemotherapy ABVD (which is a standard 4 drug sequential chemotherapy for Hodgkins Lymphoma). She finished 2 courses with accompanied side effects like hair loss and gastritis.
Her abdominal pain did not completely subside. After her 2nd Chemotherapy she developed deep vein thrombosis (DVT). She was started on heparin and later oral anticoagulation. On investigating for the cause of DVT (of which underlying malignancy is one cause) we found that she has strong and active lupus anticoagulation disease (her lupus anticoagulant and anticardiolipin antibody was strongly positive)
In case of lupus we have to rule out underlying autoimmune disease and hence ANA was done which was strongly positive. On further investigations she was proven to have systemic lupus erythematosus (SLE).
What happened next?
Her chemotherapy was stopped prematurely(actually 12 cycles are given) and she was diagnosed to have SLE and NOT hodgkins lymphoma!!
She later developed lupus nephritis and pulmonary embolism. She is currently taking oral anticoagulation (warf) and will have to do so for the rest of her life.
She actually had SLE causing mesenteric lymphadenopathy and not hodgkins lymphoma.
Take home messages from this case:
1.Small volume lymphadenopathy should be investigated properly and before
doing biopsy less non invasive tests should be done.
2 The patient was doctor with all family members being doctors and hence
immediate superspecialist consultation was made which should not be the
3.A particular superspecialist may have a biased view of his speciaity and hence
misdiagnosis can happen, as in this case.
4.Mesenteric small volume lymphadenopathy can be seen in many cases as in GI
infection and collagen vascular disease as in this case.
5.Initial report from mumbai may not be always right and the treating
oncosurgeon or oncologist should be aware of the differential diagnosis of a
6.I have worked for 7 years in UK and know many doctors all around the world
and I donot know of any other country other than India where oncosurgeons
give and decide about the chemotherapy protocol (this is my personal view).
7.We should have a tumor (cancer) board where a new diagnosis of any
malignancy should be discussed by a team and not individual. With this
approach every case would have a planned treatment protocol and this will
save a lot of time and money of our patients who continuously seek second
Lotus Hospital news:
With Dr Saket Junagade(cardiologist) joining us we will be able to manage difficult cases of Pulmonary embolism(PE) along with cases of DVT which were being admitted and treated at Lotus hospital since last 4 years. We also have all the thrombophilia profile tests like protein C and S, Antithrombin III, factor V leiden, complete lupus anticoagulant workup. The cost of these tests is much lower than in mumbai laboratories as we do it in our own lab.
We also run Lotus anticoagulation clinic where DVT and PE patients are given advice about INR and warfarin/acitrom dose adjustments. Dr Saket will be able to do IVC filter insertion if needed in severe DVT cases.
Currently we have 4 bedded ICU and by the time this newsletter reaches you we would have added another 7 bedded state of the art ICCU unit at lotus hospital.
Dr Saket Junagade’s contact number: 07774033388.