CLINICOPATHOLOGICAL CONFERENCE PEDIATRICSDurante, Esperon, Espino, Fernando, Figuracion, Flores, Fong, Francisco, Francisco, Garcia, Garcia, Garcia, Garcia, Garcia, Garimbao

SUBJECTIVE 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 allergic to shrimp diagnosed with asthma last 2007 family history of diabetes mellitus and

hypertension

OBJECTIVE 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 Admission given Omeprazole 40 mg IV OD

to prevent irritation of the esophageal mucosa due to multiple bouts of vomiting

Ist HOSPITAL DAY given Dexamethasone 2.5mg q6h

for the treatment of vasogenic edema associated with brain tumors

given Mannitol at 100 cc q6h to decrease intracranial volume

Imaging studies were also done

COURSE IN THE WARDS 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 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

LABORATORIESResult Interpretation

Calcium 2.62 Normal Magnesium 1.0 Normal Creatinine 61 Normal Uric Acid 281 Normal Sodium 143 Normal Potassium 3.7 Normal Chloride 105 Normal

LABORATORIES4/4/09 4/9/09 Interpretati

onHGB 141 128 NormalHCT 0.42 0.38 NormalPC 260 NormalWBC 10.9 NormalNeutrophils 0.66 NormalLymphocytes

0.24 Normal

Eosinophils 0.05 NormalBasophilsStabs 0.01 NormalESR 21 IncreasedBlood Type: B+

LABORATORIESResult Interpretation

Color colorless NormalTransparency clear NormalpH 7.5 NormalSpecific Gravity 1.010 NormalRBC 514 IncreasedWBC 1(100% lymphocytes) NormalTotal Protein 0.11 Slightly

decreasedGlucose 4.7 NormalPandy’s Test negative Normal

POST OP EVALUATION MRI of the spine

Normal cervical, lumbar and thoracic spine Audiometry

Normal hearing acuity CT scan

Heterogenous hyperdense lesion in the cerebellar vermis with perilesional edema and mass effect

Moderate extraventricular obstructive hydrocephalus

PRIMARY IMPRESSION:MEDULLOBLASTOMA 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 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 Signs and Symptoms

signs and symptoms of increased intracranial pressure and; headache, nausea, vomiting, mental status

changes, and hypertension cerebellar dysfunction

ataxia, poor balance, dysmetria

PRIMARY IMPRESSION:MEDULLOBLASTOMA 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 pseudorosette and Homer-Wright rosette formation

DIFFERENTIAL DIAGNOSIS:EPENDYMOMASRULED IN due to: RULED OUT due to:-Age and the gender of the patient-Headache -Projectile vomiting-Presence of some cerebellar signs

-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

DIFFERENTIAL DIAGNOSIS:CRYPTOCOCCOMA

PLAN:Diagnostic Procedures Laboratory studies

CBC, lectrolytes and liver and renal function tests

Imaging studies 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 Surgery

to relieve cerebrospinal fluid buildup to confirm the diagnosis by obtaining a

tissue sample to remove as much tumor as possible

Glucocorticoid treatment to decrease the volume of edema

surrounding brain tumors

PLAN:Treatment ventriculostomy

to divert excess cerebrospinal fluid from the brain

radiation therapy to reduce the number of left-over cells