1. 2 M, Abdominal Mass Presenter: Dr Mae Dolendo St Jude/NUH/Davao Twinning Project HL03042009

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

3. 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

4. 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

5. 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.

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

7. 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

8. 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

9. 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

10. 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 ( )
AFP: 2.66 iU/ml (NV 0-5.8)
LDH: 245 ( )
SGPT: 29 (30-65)
Crea: 23.6 (53-115)
ALP: 230 (50-136)

11. 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

14. Skeletal Survey

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