Transcript CLINICOPATHOLOGICAL CONFERENCE PEDIATRICS

CLINICOPATHOLOGICAL
CONFERENCE PEDIATRICS
Durante, Esperon, Espino, Fernando, Figuracion, Flores, Fong, Francisco,
Francisco, Garcia, Garcia, Garcia, Garcia, Garcia, Garimbao
SUBJECTIVE

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10-year-old
intermittent headache of 1 year duration
 vague
frontal headaches
 occur twice a week, usually in the late afternoons


diagnosed to have Iron Deficiency Anemia
prescribed with oral Iron preparation
SUBJECTIVE

projectile vomiting
 non-villous,
non-bloody
 amounting to half a cup
 occurs 2-3 times a day

did not experience tinnitus, gait disturbance,
gastrointestinal, and urinary problems
SUBJECTIVE


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allergic to shrimp
diagnosed with asthma last 2007
family history of diabetes mellitus and hypertension
OBJECTIVE
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slightly pale conjunctivae
+ horizontal nystagmus
GCS 15 (E4V5M6)
positive for Romberg’s sign
no motor or sensory deficit
negative for Babinski sign, ankle clonus, nuchal
rigidity, Kernig’s sign, and Brudzinski sign
COURSE IN THE WARDS
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Admission
given Omeprazole 40 mg IV OD
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Ist HOSPITAL DAY
given Dexamethasone 2.5mg q6h


for the treatment of vasogenic edema associated with brain
tumors
given Mannitol at 100 cc q6h
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to prevent irritation of the esophageal mucosa due to multiple
bouts of vomiting
to decrease intracranial volume
Imaging studies were also done
COURSE IN THE WARDS
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CSF analysis from ventricular drainage
5
cc of clear, colorless fluid
 pH of 7.5
 specific gravity of 1.010
 RBC 514 x 106
 WBC 1 x 106, 100% lymphocytes
 glucose of 4.7 mmol/L
 protein 0.11 g/L
 (-) Pandy’s
COURSE IN THE WARDS

4TH HOSPITAL DAY
 the
patient underwent an operation
 Ceftriaxone 750 mg IV was started and other
medications were continued

6th HOSPITAL DAY
 Limited
lateral eye movements on the left
COURSE IN THE WARDS
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
7TH HOSPITAL DAY
Omeprazole IV and Dexamethasone IV were
shifted to oral preparation
 no

episodes of vomiting were noted
MRI of the whole spine and liver function test
 to
evaluate for possible metastasis
LABORATORIES
Result
Interpretation
Calcium
Magnesium
Creatinine
2.62
1.0
61
Normal
Normal
Normal
Uric Acid
Sodium
Potassium
Chloride
281
143
3.7
105
Normal
Normal
Normal
Normal
LABORATORIES
4/4/09
4/9/09
Interpretation
HGB
141
128
Normal
HCT
0.42
0.38
Normal
PC
260
Normal
WBC
10.9
Normal
Neutrophils
0.66
Normal
Lymphocytes
0.24
Normal
Eosinophils
0.05
Normal
Stabs
0.01
Normal
ESR
21
Increased
Basophils
Blood Type: B+
LABORATORIES
Result
Interpretation
Color
colorless
Normal
Transparency
clear
Normal
pH
7.5
Normal
Specific Gravity
1.010
Normal
RBC
514
Increased
WBC
1(100% lymphocytes)
Normal
Total Protein
0.11
Slightly decreased
Glucose
4.7
Normal
Pandy’s Test
negative
Normal
POST OP EVALUATION
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MRI of the spine
 Normal

Audiometry
 Normal
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cervical, lumbar and thoracic spine
hearing acuity
CT scan
 Heterogenous
hyperdense lesion in the cerebellar
vermis with perilesional edema and mass effect
 Moderate extraventricular obstructive hydrocephalus
PRIMARY IMPRESSION:
MEDULLOBLASTOMA
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Primarily considered due to:
Results of the patient’s CT scan (hyperdense lesion in
the cerebellar vermis)
 most
common malignant hyperdense brain tumor arising
in the cerebellar vermis

The patient’s age (10 y/o)
 usually
seen in 0-14 years of age
PRIMARY IMPRESSION:
MEDULLOBLASTOMA

Presenting signs and symptoms
 vague
headache
 vomiting
 (+) Romberg sign
 cranial nerve deficits
PRIMARY IMPRESSION:
MEDULLOBLASTOMA
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Incidence
 accounts
for 90% of embryonal tumors
 2% of all primary brain tumors
 18% of all pediatric brain tumors
 predominately in males
 majority occur in the midline cerebellar vermis
PRIMARY IMPRESSION:
MEDULLOBLASTOMA
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Signs and Symptoms
 signs
and symptoms of increased intracranial pressure
and;
 headache,
nausea, vomiting, mental status changes, and
hypertension
 cerebellar
 ataxia,
dysfunction
poor balance, dysmetria
PRIMARY IMPRESSION:
MEDULLOBLASTOMA
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Etiology and Pathogenesis
 occur
in the posterior fossa
 30–40% = chromosome 17p deletions
 10–20% = genetic loses on chromosomes 1q and 10p
 10% = abnormalities of chromosome 9p
 arises from cerebellar stem cells
 perivascular
formation
pseudorosette and Homer-Wright rosette
DIFFERENTIAL DIAGNOSIS:
EPENDYMOMAS
RULED IN due to:
-Age and the gender of the
patient
-Headache
-Projectile vomiting
-Presence of some cerebellar
signs
RULED OUT due to:
-Absence of lower CN
affectations
-Timing of the headache in
this illness gradually
decrease during the day and
relieved by vomiting
-In CT scan this will show
heterogenous hyperdense
lesion
DIFFERENTIAL DIAGNOSIS:
HEMANGIOBLASTOMA
RULED IN due to:
-Long history of headache (1
year)
-Vomiting
-Predominant in males
-presence of some cerebellar
signs
RULED OUT due to:
- low incidence in the
pediatric age group
-seen as a hypodense mass
with associated
hydrocephalus
DIFFERENTIAL DIAGNOSIS:
CRYPTOCOCCOMA
RULED IN due to:
-Intermittent headache
-projectile vomiting
-CSF analysis of the patient
which revealed 100%
lymphocytes
-hyperdense lesion on CT
scan
RULED OUT due to:
-CSF analysis was
unremarkable for a
cryptococcal etiology
-improvement with this
disease is noted with
administration of IV
Amphotericin B which was not
given to the patient
PLAN:
Diagnostic Procedures

Laboratory studies


Imaging studies
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CBC, lectrolytes and liver and renal function tests
CT scan, MRI, and bone scan
Other procedures
audiography or brainstem auditory-evoked response,
 lumbar Puncture
 bone marrow aspirate
 biopsy and histologic study of the specimen

PLAN:
Treatment
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Surgery
 to
relieve cerebrospinal fluid buildup
 to confirm the diagnosis by obtaining a tissue sample
 to remove as much tumor as possible
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Glucocorticoid treatment
 to
decrease the volume of edema surrounding brain
tumors
PLAN:
Treatment
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ventriculostomy
 to
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divert excess cerebrospinal fluid from the brain
radiation therapy
 to
reduce the number of left-over cells