1. CLINICOPATHOLOGICAL CONFERENCE PEDIATRICS Durante, Esperon, Espino, Fernando, Figuracion, Flores, Fong, Francisco, Francisco, Garcia, Garcia, Garcia, Garcia, Garcia, Garimbao

2. 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

3. 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

4. SUBJECTIVE  allergic to shrimp  diagnosed with asthma last 2007  family history of diabetes mellitus and hypertension

5. 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

6. COURSE IN THE WARDS  Admission  given Omeprazole 40 mg IV OD  to prevent irritation of the esophageal mucosa due to multiple bouts of vomiting  I st 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

7. 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 10 6  WBC 1 x 10 6, 100% lymphocytes  glucose of 4.7 mmol/L  protein 0.11 g/L  (-) Pandy’s

8. COURSE IN THE WARDS  4 TH HOSPITAL DAY  the patient underwent an operation  Ceftriaxone 750 mg IV was started and other medications were continued  6 th HOSPITAL DAY  Limited lateral eye movements on the left

9. COURSE IN THE WARDS  7 TH 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

10. LABORATORIES ResultInterpretation Calcium2.62Normal Magnesium1.0Normal Creatinine61Normal Uric Acid281Normal Sodium143Normal Potassium3.7Normal Chloride105Normal

11. LABORATORIES 4/4/094/9/09Interpretation HGB141128Normal HCT0.420.38Normal PC260Normal WBC10.9Normal Neutrophils0.66Normal Lymphocytes0.24Normal Eosinophils0.05Normal Basophils Stabs0.01Normal ESR21Increased Blood Type: B+

12. LABORATORIES ResultInterpretation Colorcolorless Normal Transparencyclear Normal pH7.5 Normal Specific Gravity1.010 Normal RBC514 Increased WBC1(100% lymphocytes) Normal Total Protein0.11 Slightly decreased Glucose4.7 Normal Pandy’s Testnegative Normal

13. 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

14. 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

15. PRIMARY IMPRESSION: MEDULLOBLASTOMA  Presenting signs and symptoms  vague headache  vomiting  (+) Romberg sign  cranial nerve deficits

16. 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

17. 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

18. 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

19. DIFFERENTIAL DIAGNOSIS: EPENDYMOMAS RULED 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

20. DIFFERENTIAL DIAGNOSIS: HEMANGIOBLASTOMA

21. DIFFERENTIAL DIAGNOSIS: CRYPTOCOCCOMA

22. 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

23. 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

24. PLAN: Treatment  ventriculostomy  to divert excess cerebrospinal fluid from the brain  radiation therapy  to reduce the number of left-over cells