1. Joseph Tigarea Paediatric Registrar CWM Hospital
CASE DISCUSSION
Joseph Tigarea
Paediatric Registrar
CWM Hospital

2. Carol is a 9 year old retrieved from Fulaga Island

3. She was admitted with us in June 2015 at the age of 9 with a history of; • Severe headache • Vomiting • Poor appetite • Increasing weakness • Ataxia and blurry vision

4. Headaches: Usually starts in the morning and lasts all day, not worsened at any particular time of the day. Headaches progressively worsened over 1 year and would be temporarily relieved by paracetamol. 3 weeks prior, headaches worsened in intensity and would be associated with vomiting, blurry vision and ataxia. Malaise- She’s generally weak and unable to walk straight Appetite had been poor and according to family, she hadn’t been eating as well as she used to. She had been traditionally treated for about a year with no improvement.

5. Her pediatric history was unremarkable
Her pediatric history was unremarkable. She was born at term via normal delivery with a birth weight of 2.7kg. There were no perinatal complications. According to her mother she her development was normal even in comparison with her 3 younger siblings. She was the oldest of 4 siblings and there wasn’t any history of cancer in the family.

6. Examination on admission: She was weak looking and unable to stand, and was moaning in pain because of her headaches. Both her pupils were equal and reactive to light GCS- 15/15 HR- 80’s RR_ 25 Temp- 36 Sats were maintained in RA at 98% BP- 129/84 CBG- 6.6

7. Chest and abdominal examination were unremarkable
Chest and abdominal examination were unremarkable. Neurology: Power in all her limbs were around 4/5 Normal tone Reflexes were brisk and Babinskis’ was negative in both feet Cranial nerve examination was not done Coordination: there was no pass pointing and heel to shin test was normal

8. Impression on admission was; 1. Space occupying lesion 2
Impression on admission was; 1. Space occupying lesion 2. Rule out and infective cause

9. She was admitted into our ICU and arrangements were made for an MRI and an urgent Neurosurgical and eye referral was made. She was also commenced on dexamethasone and cephalothin and following Fundoscopy was also given mannitol Fundoscopy: Disc margins not clearly demarcated- swollen discs bilaterally No retinal hemorrhages

10. MRI: Gross hydrocephalus Large 5X5cm posterior fossa space occupying lesion with solid and cystic components Attached to Lt cerebellar peduncle and extends to quadrigeminal cistern to lie in close proximity to deep veins (vein of Galen and straight sinus) and pineal gland.

11. Following the MRI a VP shunt was inserted and plans for craniotomy and debulking was made. On Day 7 of admission: She was taken in for craniotomy and tumor debulking and a biopsy of the tumor was sent.

12. Post op Day 1, she was unarousable, though her vitals were stable
Post op Day 1, she was unarousable, though her vitals were stable. Her GCS was 9/15 Neurosurgical team queried a postoperative shunt blockage Vs a postoperative bleed. A repeat MRI was done which excluded this.

13. Patient slowly picked up over the next few days post op
Patient slowly picked up over the next few days post op. We had started Carol on Physiotherapy and started her on NG feeds with the help of our dietician. On Day 6 post debulking- her GCS dropped from 13 to 10/15 and her pupils became unequal RT-2mm LT-4mm. Over the next 2 days her GCS continued to drop and patient became comatose. Fundoscopy was done but no papilledema was documented. Parents were updated on her condition and poor prognosis.

14. Day 8 post Op: GCS-3/15 and parents reminded of guarded prognosis
Day 8 post Op: GCS-3/15 and parents reminded of guarded prognosis. Day 9 post Debulking: GCS remained 3/15, and child developed a fever. She was screened and commenced on Meropenem. Developed pressure sores on Day 11. Day 19: patient’s GCS still 3/15 but vitals remained stable so parents were advised on possible home once antibiotics were completed. We continued to work together with our physiotherapy team and the dieticians. Parents were counselled on type of feeds and how to give NG feeds at home. Patient was planned for palliative care.

15. Patient’s condition remained the same and was discharged at Day 29 post tumor debulking. Since discharge, patient was reviewed over the next 2 months for change of NGT and general checkup. Patient was last reviewed with us November last year before she was sent back to Fulaga Island where she resides.

16. Challenges/Issues: VP shunt insertion Treating with antibiotics (palliative case) Ongoing contact and support of family on discharge. Poor Documentation on patient progress