CASE STUDY
10/6/2023
IMMUNO
SEROLOGY
Patient Presentation
A 59 year old male presents to the medical out patient department with a one month history of
progressively increasing fatigue and backache.
History
For the last month the patient has been feeling exhausted for no apparent reason and due to
this extreme tiredness, is finding it difficult to work and look after himself. He comes home in
the late afternoon often too tired to eat and goes straight to bed; a change from his former
energetic lifestyle.
He has also been complaining of some backache which he treats with over the counter
analgesics and he has been suffering from more colds and flu then usual over the last year.
He has also found that for the last 6 months there has been a decline in his ability to speak
clearly. His tongue has enlarged and become firm which makes moving it for speech
formation and eating solid foods difficult and at times painful.

He has had an unintentional weight loss of ± 15kg in the last 6 months.

Past medical history

Previously well, no chronic disease, no previous admissions.

Past surgical history

No history of any surgical procedures.
Family History




Father died of a myocardial infarction at age 63 yrs with hypercholesterolaemia.
Mother has hypertension on treatment and reports good control.
No positive family history for any other chronic diseases including diabetes and cancer.
Social history




Lives alone in a town house.
Employed as an accountant.
30 year history of smoking.
Significant alcohol history for 12 years, now in recovery for the last 5 years.
Differential Diagnosis

Anaemia

Vitamin B12/folate deficiency

Heart failure

Malignancy

Multiple myeloma

Monoclonal gammopathy of undetermined significance (MGUS)

Waldenstrom’s macroglobulinaemia
Examination
General

Ill looking, pale and underweight middle-aged gentleman
CASE STUDY
10/6/2023
IMMUNO
SEROLOGY

Awake and alert, able to give an accurate history

Significant dysarthria for the last 3 months, making him difficult to understand.
Vitals

Afebrile

Blood pressure 100/68

Heart rate 84

Respiratory rate 18
General

Mild pallor

No lymphadenopathy

No signs of dehydration

No jaundice

No oedema

No stigmata of HIV

Tongue red and enlarged with deep imprints from the teeth on both sides of the
tongue. Very reduced mobility; unable to protrude or lift up and very limited sideways
movement.
Respiratory

Trachea centrally located.

Chest clear on auscultation.
Cardiovascular

No raised JVP

Normally placed apex beat

S1 and S2 heart sounds present, no murmurs.

No abnormalities detected
Abdomen

Not distended

Soft and non tender

Bowel sounds present

No abnormalities detected
Neurological

Higher function intact, although difficult to understand

Gait normal
CASE STUDY
10/6/2023
IMMUNO
SEROLOGY

Power 5/5 globally

Tone normal globally

Reflexes 2/4 for both upper and lower limbs

No abnormalities detected
Dermatological/Haematlogical

Some small bruises on arms and legs of various ages

No rashes

No petaechial bleeds
Examination
Normal
Limits
Value
admission
Day 3
Da
y6
Day 9
WBC
5.79
6.26
6.5
6
6.04
(4-12
x109/L)
HB
5.4
12.8
10.
9
13
(12.115.2 g/L)
Platelets
150
129
97
130
(140-450
x109/L)
CRP
18
14
(0-8mg/L)
Differential :
Neutrophils
8.73
(2.00-7.5)
Monocytes
0.41
(0.180.80)
Lymphocytes
0.57999999999999
996
(1.004.00)
Erythrocytes
0.03
(0.000.45)
Basophils
0.02
(0.000.20)
NA
139
140
141
146
(135-147
mmol/L)
K
6
5.3
5.4
6.2
(3.3-5.0
mmol/L)
CL
105
108
110
119
(99-103
µmol/L)
CASE STUDY
10/6/2023
IMMUNO
SEROLOGY
Examination
Normal
Limits
Value
C02
18
16
18
11
(18-29
mmol/L)
Urea
23
32
37
45
(2.5-6.4
mmol/L)
Creatinine
390
291
262
316
(62-115
mmol/L)
Total protein
61
69
71
(6080g/L)
Albumin
35
31
33
(3550g/L)
Corrected
Calcium
3.09
3.1
2.9
6
2.8
(2.12.6mmol/
L)
Phosphate
2.41
1.88
1.8
7
1.83
(1.0-1.5
mmol/L)
Magnesium
1.1599999999999
999
1.01
0.9
7
1.02
(0.8-1.3)
IgG
3.24
(4-10)
IgM
25.7
(0.5-2.2)
IgA
(0.5-2.2)
B-2
microglobuli
n
HIV Elisa
Hepatitis
studies, A, B
and C
22.3
negative
All negative
Blood
Culture
Bence Jones
Protein
Bone Marrow
Aspiratephenotypic
markers:
(
Negativ
e
Positive
CASE STUDY
10/6/2023
IMMUNO
SEROLOGY
Examination
Normal
Limits
Value
CD38
Increased levels
detected
CD138
Increased levels
detected
Protein
Electrophore
sis
M band
Patient Diagnosis : Multiple myeloma
1. What cell type becomes neoplastic and is implicated in patient’s condition?
A. Plasma B Cells
B. Memory T cells
C. Dendritic Cells
Explain your answer:
CASE STUDY
10/6/2023
IMMUNO
SEROLOGY
Patient Presentation # 2
A 55-year old HIV-infected male was referred to the Dermatology Outpatient Clinic with a four
month history of a swollen face and multiple skin nodules.
History
Three years prior to this presentation, the patient was treated at his local clinic for a persistent
rash, diagnosed as eczema. There was minimal response to a standard therapy of topical
steroids, he experienced only a minimal response.
Past Medical History
He was diagnosed with pulmonary tuberculosis (TB) and tested positive for HIV at the same
time. He completed six months of standard TB treatment.
His CD4 count over three months showed a steady decline:
1st measurement: CD4 count was 987 cells/ul
3 months later his CD4 count was 603 cells/ul
HAART was initiated five months later when his CD4 count dropped below 350 cells/ul. He
was started on antiretroviral therapy (ARV), consisting of lamivudine (3TC), stavudine (d4T)
and efavirenz (EFV)
He defaulted treatment and was lost to follow-up for more than a year.
When he returned to the clinic he was re-initiated on ARV. Four months after restarting
treatment he developed facial swelling and bulky, non-tender nodules on the trunk and limbs.
A skin biopsy showed dermal infiltration of atypical lymphoid cells.
Following his biopsy results, he was referred to a specialist skin lymphoma clinic.
Past Surgical History
Previous laparotomy for small bowel obstruction, cause unknown.
Family History
Nothing of significance
Allergies
None known
Medication
Topical steroids
ARV: 3TC, d4T and EFV
Travel History
None noted
Social History
Non-smoker
No alcohol use
CASE STUDY
10/6/2023
IMMUNO
SEROLOGY
No illegal substance use
Examination
Appearance: ambulatory, underweight, erythrodermic male, awake, alert and co-operative.
Vitals

Temperature: afebrile

Blood pressure: 124/76

Heart rate: 75

Respiratory rate: 16
General

Erythrodermic, skin, generally indurated

Palpable axillary and groin lymph nodes

No jaundice, pallor or oedema
Chest

Chest clear
Cardiovascular

Normotensive

No murmurs, no added heart sounds
Abdomen

Mild tenderness over the liver and the spleen with accompanying
hepatosplenomegaly.
Neurological

No abnormalities detected
Dermatological

Erythrodermic, skin generally indurated

Diffusely indurated face with leonine features

Boggy non-tender multiple nodules and tumors on the face, of varying sizes

Similar tumourous nodules on thighs

Fine non-palpable purpuric rash on upper the trunk

Non-tender tumourous nodules on forearm


CASE STUDY
10/6/2023
IMMUNO
SEROLOGY

On Admission
6
14
weeks weeks Reference
(Feb (Marchranges
2012) 2012)
WCC +peripheral
smear
50.51 with > 10% circulating
atypical lymphocytes
8.6
11.1
4-12x109/L
Hb
13.3
10.6
7.4
12.1-15.2g/L
MCV
105
79-98.9fL
MCH
33.4
27-32.0pg
MCHC
31.8
32-36.0g/dL
Platelets
383
93
130
140450x109/L
Diff Count:
Neutrophils
6.57
2.0-7.50
x109/L
Lymphocytes
34.35
1-4x109/L
Monocytes
3.54
0.18 – 0.80
x109L
Eosinophils
1.01
0.0 – 0.45 x10
9 /L
CD4 count
94
Viral Load
1890

Final Diagnosis :HIV with Sezary syndrome stage IVB
2. In Patient case # 2, which cells recirculates and can clonally expand and
differentiate?
A. T-cells (Central Memory T-cells)
B. B cells
C. Red blood cells
Explain your answer:
3. In Patient case # 2, what is the fate of effector cells after antigens has been cleared?
A. Apoptosis
B. Phagocytosis
Explain your Answer: