Conversation 5

The following clinical details are based on written information in the discharge booklet given to this patient.

December 2013: A 14 year old girl is admitted for distension of abdomen. She is noted to have gross ascites. She undergoes abdominal paracentesis, feels better and is discharged at her own request before the clinical work-up is complete. The discharge diagnosis is : ASCITES FOR INVESTIGATION

January 2014: She presents with generalised tonic-clonic seizures. No abnormal findings on examination. She is treated with anticonvulsant medication. The diagnosis is EPILEPSY

March 2014: She presents with poor appetite, loss of weight of 3 kg in the past 4 months and generalised body weakness. She is noted to have slight ascites and a palpable spleen. She undergoes another abdominal paracentesis which shows yellowish peritoneal fluid. She does not have any stigmata of chronic liver disease. She does not have a KF ring in her cornea. An ultrasound of the liver done later shows features of early liver cirrhosis. The LFT is normal. Antibodies to Hepatitis B and c are negative. Urine examination is normal. The Hemoglobin is 10.2gm/dL, the WBC count and platelet count are both normal. The discharge diagnosis is TO RULE OUT WILSON'S DISEASE

April 2014: She develops seizures again. CT brain shows multiple space occupying lesions with cerebral edema. CT abdomen shows a mass in the pelvis involving the ovaries and uterus. She is diagnosed with OVARIAN CANCER WITH METASTASES TO THE BRAIN

May 2014: She undergoes total abdominal hysterectomy. HPE of the abdominal mass shows features of tuberculosis with no evidence of malignancy. She is treated with anti TB treatment, dexamethasone, anticonvulsants and the estrogen Premarin is added later.

May 2015: She is asymptomatic and a repeat CT brain shows the brain lesions have all disappeared. Anti TB treatment is stopped. The anticonvulsant medication and Premarin are continued.

December 2015: The anticonvulsants are tapered down with the intention of stopping them. She is advised life long Premarin. The final diagnosis is PELVIC TUBERCULOSIS WITH TUBERCULOMAS IN THE BRAIN

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