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

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

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

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  1. 2 M, Abdominal MassPresenter: Dr Mae DolendoSt Jude/NUH/Davao Twinning ProjectHL03042009

  2. NB • 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 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 (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)

  11. CT scan of thorax/whole abdomen: • Pneumonia, Left upper lobe with mediastinallymphadenopathy • 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

  12. Skeletal Survey

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

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