Patient: HMA

Age/Sex: 6y/M
Civil Status: Single
Nationality/Citizenship: Filipino
Home Address: Rizal
Religion: Roman Catholic
Date of Admission: 2/13/2022
Informant: Mother

Chief Complaint: Gait Imbalance

History of Present Illness:

Three months PTA, parents noted medial deviation of his right eye when looking straight with blurring of vision which prompted consult
with a private pediatrician. He was referred to an ophthalmologist where he was assessed with astigmatism and given prescription
glasses. Noted progression of symptoms after 1 week, now with nape pain, dizziness, vomiting of previously ingested food, non-bilious,
non-projectile amounting to ½ cup per day, and a head tilt. No other symptoms noted. On follow up with same pediatrician, requested
for CBC and Xray which were unremarkable. Referred to Orth surgery due to nape pain and head tilt interpreted as a “stiff neck”. No
medications were given and they were advised to do observation.

Two months PTA, still with the symptoms but now with wide-based gait with frequent falls to the right. They sought consult with another
pediatrician with an assessment of neurologic problem probably intracranial mass hence, they were referred to a child neurologist. On
teleconsult with a child neurologist, assessment was a brain cyst and was given domperidone 0.28 mkdose every 8 hours as needed
for vomiting. A cranial MRI with contrast was requested however due to financial constraints, was delayed.

Five weeks PTA, there was increased frequency of vomiting of the same character occurring three times per day, worsening of gait
imbalance and more frequent falls, now accompanied by unintentional weight loss of 8kg over 3 months (26.8% weight loss). Cranial
MRI with contrast was done at this time.

Three weeks PTA, he followed up with the child neurologist and was prescribed with acetazolamide 5.6mkday BID & to continue
Domperidone (same dose) and was referred to neurosurgery and advised admission.

Review of systems:

General: (-)fever
HEENT: (-) hair loss, (-) ear discharge, (-) ear pruritus, (-) ear pain, (-) sore throat, (-) dysphagia, (-) oral ulcers
Cardiovascular: (-) cyanosis, (-) chest pain, (-)palpitation
Respiratory: (-)dyspnea (-) cough
Gastrointestinal: (-) abdodimal pain (-) diarrhea (-) constipation
Genitourinary: (-) hematuria, (-) bubbly urine, (-) genital ulcers
Endocrine: (-) polyuria, (-) polydipsia, (-) polyphagia
Musculoskeletal: (-) joint pains, (-) joint swelling, (-) limitation of motion
Hematopoietic: (-) pallor, (-) bleeding, (-) easy bruisability
Skin: (-)rash

Personal History:

Feeding History:

QUANTITY CALORIES
Breakfast 1 serving sinabawang gulay at isda + 1 cup rice 254 + 210+153
1 serving full-cream milk
Lunch 1 serving halaan + 1 cup rice 150 + 210

Snack 1 serving kamotecue 239

Dinner 1 serving hasa-hasa + 1 cup rice 155 + 210
Actual Caloric Intake 1581
Dietary Reference Intake 1600
% Deficiency 1.2%

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Immunization History: Updated up to 9 months old, no booster doses. Latest vaccine: Influenza (April 2020).

Past Medical History

Acute Gastritis (2020)
No history of trauma or accidents, neurologic disorders and previous surgeries

Family History
(+) Hypertension - father
(+) Anemia – mother
(+) Bronchial asthma - paternal side
(-) neurologic disorders
(-) Cancer

PHYSICAL EXAMINATION
General survey: conscious, coherent, not in distress, ill-looking, well-hydrated, severely-wasted, wheelchair-borne
VS: BP 100/70 mmHg, HR 80 bpm, RR 21 cpm, T 36.7C, 02 sat 99% at room air
Anthropometrics: Wt 18kg (z below -1), Lt 130cm (z above +1), BMI: 10.7 (z below -3), HC 52cm (at p50)
Skin: warm, moist, good skin turgor
Head: symmetrical, no lesions, no masses
Eyes: anicteric sclerae, pink palpebral conjunctivae
Ears: no tragal tenderness, nonhyperemic EAC, (+)retained cerumen, AU, intact TM
Nose: nasal septum midline, no discharge
Mouth/Thoat: moist lips and buccal mucosa, (+)dental caries, nonhyperemic posterior pharyngeal wall, (+) grade 2 tonsils
Neck: no cervical lymphadenopathy
Lung: no retractions, symmetrical chest expansion, clear breath sounds
Heart: adynamic precordium, apex beat at 4th LICS MCL, no heaves/lifts/thrills, no murmurs
Abdomen: flat, normoactive bowel sounds (12 clicks/min), tympanitic, soft, nontender
Extremities: full and equal pulses, CRT <2s
Genitalia: grossly male

Neurologic Examination:
GCS 15, awake, conversant, coherent, oriented to person and place, poor attention, recall judgment
Cranial nerves:
I: not assessed
II: (+)blurred disc margins, bilateral; RAPD, bilateral; VA 20/70 OS, 20/200-1 OD
III, IV, VI: isocoric pupils 3-4mm ERTL sluggish; lateral rectus palsy, OU
V: corneal reflex, intact temporalis and masseter, facial sensation intact
VII: left peripheral facial palsy
VIII: gross hearing intact
IX, X: no dysarthria/drooling/dysphagia, (+)gag reflex
XI: can turn head and shrug shoulders against resistance
XII: tongue deviated to the right
Generalized muscle wasting, good bulk
Motor: 4/5 on all extremities
Pronator drift, right
Normoreflexic
No sensory deficit to light touch
Cerebellar: (+)dysmetria, (+)dysdiachokinesia,
(+) truncal ataxia, unable to stand alone, walk assisted scissoring of bilateral LE
(+) Babinski, bilateral
No meningeal signs

which showed: 1. Intraventricular mass in the 4th ventricle measuring 5x4x4.7cm. Primary considerations: Ependymoma,
Medulloblastoma, Pilocytic astrocytoma 2. Obstructive hydrocephalus with trans ependymal seepage.
Admitting Diagnosis: Intraventricular tumor with obstructive hydrocephalus

COURSE IN THE WARD

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Upon admission, he was scheduled for VPS insertion followed by posterior fossa tumor surgery. Heplock was placed, he was started on
Mannitol 0.26g/kg/dose and Cefazolin on call to OR. The following laboratory tests were requested: CBC, serum Na, K and Cl, blood
typing, Chest Xray, and SARS-COV-2 RT-PCR. He was referred to Child Neurology with the same assessment. He was likewise
started on dexamethasone 0.1 mkdose loading dose then 1.1 mkdose Q6 as maintenance dose. A preoperative risk 3 assessment was
given.

On the 3rd hospital day, he had dizziness with generalized headache graded 9-10/10, and 2 episodes of vomiting of previously ingested
food, nonbilious, nonprojectile ~90ml which was replaced by ORS. Neurologic Exam status quo. Mannitol was increased to
0.5g/kg/dose. There was partial improvement of symptoms however later that day, became unarousable. GCS7 (E1V2M4), blood
pressure was elevated at 130/80 mmHg, HR went down to 80’s bpm, and RR down to 12 cpm,. Stat HGT was 143 mg/dL. He was
intubated and hooked to mechanical ventilator. This was followed by 1 episode of seizure described as stiffening of extremities lasting
for 10 seconds. Diazepam 0.3 mkdose was given with noted resolution. In addition, Levetiracetam 20 mkdose as loading dose and then
20 mkdose every 12 hours was started. Due to progression of symptoms, underwent emergency VPS insertion followed by sub parietal
craniotomy with C1 laminectomy. After induction of anesthesia, he had hypotensive episodes at 71/54 mmHg, hence PNSS 11ml/kg
bolus was given, BP went up to 83/54 mmHg with mean arterial pressure of 64 afterwards. Intraoperatively, they proceeded with VPS
insertion which was patent with good shunt rebound. Following this, posterior fossa tumor debulking was done wherein a mass was
seen through the cerebellar tonsils which seemed to be enclosing the posterior inferior cerebellar artery. At that time, blood loss was
already 200ml with an allowable blood loss of 300ml, hence 1u pRBC at 15cc/kg was given. Intraoperative findings showed reddish to
grayish multilobulated friable vascularized lesion ~6cm widest diameter; right tumor adherent to the right vascularized fossa and at the
middle cerebellar peduncle; tonsils found at the C1 level. Hence C1 laminectomy was done. Also during debulking, there was another
hypotensive episode of 60/40 mmHg which resolved spontaneously after tumor manipulation. Total blood loss was 700ml hence,
another 2u pRBC were given.

On the 4th Hospital day, he was admitted at the Pediatric ICU post operatively and was given the following medications: Cefazolin at
111mkday q8, Midazolam drip 0.9mcg/kg/min, Paracetamol 11mkdose q6 RTC, Ketorolac 0.5mkdose q6 RTC for 24 hours,
Esomeprazole 20mg/dose QD, Levetiracetam 20mkday q12, Dexamethasone 20mg/day q6, and Mannitol 0.5g/kg/dose q6. Repeat
CBC and electrolytes were done. Diet was eventually progressed and a repeat Cranial MRI with contrast was done which showed
Interval decrease in size of the heterogeneously enhancing mass within the 4th ventricle now measuring 2.6x2.4x3.7cm (previously,
4.8x4.4x6.0cm) and interval regression in the degree of obstructive hydrocephalus with transependymal seepage.

During the rest of the hospital stay, oxygen supplementation was discontinued and medications were completed. He was referred to
rehabilitation medicine for physical therapy and hematology-oncology for further evaluation and management. The rest were
unremarkable.

Final Histopathology Results: MEDULLOBLASTOMA (WHO GR IV), LARGE CELL ANAPLASTIC HISTOLOGY Synaptophysin: (+)
in majority of tumor cells GFAP: (+) in occasional tumor cells Reticulin: (-) for nodular pattern

LABORATORY RESULTS

CBC w/ plt Reference Range 02/14 02/18

Hgb 120-140g/L 132 163

Hct 0.37-0.41 0.38 0.48

MCV 78-90 fl 79.40 76.20

MCH 29+/-2pg 27.40 26.0

MCHC 33+/-3 g/dL 34.50 34.10

Plt 150-350 x 109/L 349 207

WBC 4.5-13.5 x 109/L 7.8 11.9

Neutrophils 0.55-0.70 0.42 0.74

Metamyelocyte -

Bands 0.00-0.05 -

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 Segmenters 0.55-0.65 0.42 0.74

Lymphocyte 0.25-0.35 0.51 0.23

Monocytes 0.03-0.06 0.02 0.03

Eosinophils 0.02-0.04 0.05 -

Basophils 0.00-0.01 - -

Reference 02/14 02/18 2/18 (post

range correction)
Na 136-143 135 147 148
K 3.4-4.7 3.54 3.08 3.71
Cl 111 112.3

Reference range 02/14

PT 10.3-14.1 12.0
Normal control 12.6
PTT 27.0-45.4 33.8
Normal control 31.0
INR 0.8-1.3 1.0

Intraventricular mass in the 4th ventricle. Whole spine MRI with contrast showed: 1. No abnormal enhancement in the entire spinal
cord, 2. Slight straightened lumbar spine may be dt muscle spasm, 3. Incidental findings of intraventricular mass within the 4th ventricle
causing cerebellar tonsillar herniation that is unchanged since the previous MRI scan. They were scheduled for surgery, hence
admission.

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