2 M, Abdominal Mass Presenter: Dr Mae Dolendo St Jude/NUH/Davao Twinning Project HL03042009

Malungon, Sarangani Province NB 2/M Malungon, Sarangani Province Informant: grandmother % Reliability: 30%

Background Youngest child of a 26G4P4 mother Immunization history: unknown (+) history of goiter in the family (+) Tb exposure (grandfather) Developmental milestones: At par with age except for motor Still cannot walk without support at 2 years old

HPI 1 yr PTA: hx of fall 3x, 1 from a hammock and 2x from the stairs approximately 2 feet from the ground (+) gradually enlarging lumbar mass (+) intermittent fever and cough no consult done

HPI 3 mos PTA Patient was left by his mother to his grandmother The lumbar mass was still increasing in size with note of thoracolumbar deformity and increasing abdominal girth.

HPI 1 mos PTA Admitted at a local hospital Treated with: Ampicillin for pneumonia INH and Rifampicin for tuberculosis

HPI Work-ups done at the local hospital CBC: Hb 67, Hct 0.26, WBC 19.6 transfused with pRBC USD of whole abdomen: normal sized liver with slight parenchymal echogenicity normal GB, pancreas, spleen, kidneys and urinary bladder Biopsy of the inguinal mass: chronic granulomatous inflammation with few Langerhans type giant cells suggestive of tuberculosis Transferred for further evaluation and management

PE Awake, afebrile, non-ambulatory (-) rashes RR: 42/min HR: 136/min Temp: 37.1C Wt: 10kg Ht: 72cm (-) rashes Pinkish palpebral conjunctivae, anicteric sclerae, no ear discharges (+) CLAD

PE (+) crackles BLF >Left, (+) spinal deformity kyphosis with mass on the thoraco-lumbar area, soft, irregular 16x14 cm AG: 50.5cm, soft, nontender, (+) abdominal mass 12cm R subcostal margin crossing the midline, (+) inguinal LAD 1-1.5cm R inguinal region Full pulses, (-) deformities on all extremities

Laboratories CBC: Hb 109 Hct 0.37 WBC 16.3 Seg 55 Lymph 33 Plt 566 Na: 146 K: 4.4 Ca: 2.34 Uric acid: 0.22 (0.24-0.42) AFP: 2.66 iU/ml (NV 0-5.8) LDH: 245 (100-190) SGPT: 29 (30-65) Crea: 23.6 (53-115) ALP: 230 (50-136)

CT scan of thorax/whole abdomen: Pneumonia, Left upper lobe with mediastinal lymphadenopathy Multiple osteolytic changes, thoracic spine and axial spine with marrow replacement and expansion of bilateral iliac wings and thecal space, paravertebral and soft tissue infiltrations Broad spectrum disease process: underlying reticuloendothelial malignancy or diffuse metastatic disease may be considered, biopsy correlation suggested

Skeletal Survey

Discussion What are possible differentials? Further work-ups Management issues