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Senior Case Presentation

Senior Case Presentation. Armi Azad, M.D. Introduction. S.R. is a 4 y/o HF transferred from MVCH for higher level of care Chief Complaint : Intermittent fever x 1 month (ranging from 100.4 to 103 º) and R hip pain for the past couple of weeks; no hx. of trauma. Review of Systems.

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Senior Case Presentation

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  1. Senior Case Presentation Armi Azad, M.D.

  2. Introduction • S.R. is a 4 y/o HF transferred from MVCH for higher level of care • Chief Complaint: Intermittent fever x 1 month (ranging from 100.4 to 103º) and R hip pain for the past couple of weeks; no hx. of trauma

  3. Review of Systems • On further questioning: +occasional abdominal pain generalized weakness and fatigue ?decreased appetite • ROS otherwise negative

  4. PMHx Strep Throat x 1 month ago, tx’d w/ PO Abx. x10 dys.

  5. PSHx No Surgical History

  6. Birth Hx Full Term C/S 2/2 failure to progress Birth Wt= 8 lbs.

  7. Family History Mother Denies

  8. Social History Lives with both parents 2 older siblings No sick contacts No pets No tobacco exposure Pre-school waiting List

  9. History Cont’d. • Development- Appropriate • Diet- Regular • Meds- Motrin • Allergies- Amoxicillin  rash • Immunizations- Up to date

  10. Physical Exam Vital Signs: T=101.5 P=115 R=24 BP=84/59 Wt= 17 kg Height= 103 cm

  11. Physical Exam • Gen- pale, scared/anxious • HEENT- normocephalic, PERRLA neck supple no lymphadenopathy throat clear TM’s clear B/L

  12. Physical Exam • CV- RRR, 2/6 systolic murmur • Resp- CTA B/L • Abd- Soft, ND, +BS +tenderness to deep palpation RLQ no CVA tenderness

  13. Physical Exam • MS- Decreased abduction R hip 2/2 pain, +TTP R lower back (no bony TTP), 5/5 motor strength x 4 extremities +sensation intact B/L DTR’s intact B/L • Neuro- AAOx3, CN’s II-XII grossly intact, gait WNL

  14. What tests do you want to order?

  15. Diagnostic Testing • CBC w/ peripheral smear • CMP • UA, UCx/Blood Cx. • Pelvis and R hip x-rays • ESR, CRP, ASO titer

  16. 7.8 6.8 423 23.1 MCV= 76.3 ESR= >140 CRP= 13.7 ASO= 15 (<150) Segs= 19 (37-80%) Lymphs= 57 (25-35%) Mono= 5 (0-12%) Eos= 1 (0-7%) Bands= 17 (0-6%) Laboratory Results

  17. Laboratory Results 137 103 12 86 5.0 28 0.4 Albumin= 3.3 Ca= 9.6 Total Protein= 7.0 BiliT= 0.2 AST= 54 AlkPhos= 150 ALT= 14 Retic= 2.4%

  18. Urine Analysis • Color yellow • Glucose negative • Bili negative • Blood negative • Nitrite moderate • LE 2+ • WBC 5-10 • RBC 0-2

  19. Laboratory Results • Urine Cx- negative • Blood Cx’s- negative x2

  20. X-ray • Pelvis and R hip x-rays: unremarkable

  21. Any Thoughts?

  22. Differential Diagnoses of Hip Pain1

  23. Now What?

  24. Radiology • CT Pelvis: • Large fecal collection in rectum • Thickening of urinary bladder • No evidence of acute osteo or a pelvic abscess

  25. Update • Continued fevers despite IV Abx • Migratory bone pain (i.e. L shoulder, mid back) • Intermittent RLQ abdominal tenderness to deep palpation 6.7 8.0 372 19.9

  26. 3- Phase Bone Scan • Vascular Flow Study- No abn. Increased vascular flow in lower abdomen, pelvis, and thighs • Blood Pool Phase- Slight hyperemia in the right medial ilium

  27. 3- Phase Bone Scan • 3-hr Delayed Static Images- Abn. accumulation in R mastoid and clivus Abn. accumulation in body of C2/C3 Mild generalized accumulation in bodies of L3/L4 and multiple levels of the thoracic vertebrae Non-functional R kidney

  28. Bone Scan Images

  29. Impression Metastases vs. Extensive Diffuse Osteomyelitis

  30. More Radiology • CT Chest w/ contrast- Multiple osteolytic and osteoblastic lesions in the thoracic spine • CT Abd/Pelvis w/ contrast- 3.6 cm L adrenal mass No ascites or adenopathy Osteolytic lesion in R posteromedial ilium w/ sclerotic rim

  31. Neuroblastoma • What is it? • 4th most common malignancy of childhood • Cancerous tumor that begins in nerve tissue of infants and very young children • Usually begins in tissues of adrenal gland (sometimes in neck, chest, and/or pelvis)

  32. Neuroblastoma • Metastasizes quickly (i.e. LN’s, liver, lungs, bones, CNS, bone marrow) • 70% of all children diagnosed have some metastatic disease

  33. Frequency3 • Approx. 650 new cases dx’d in U.S./year • More common in whites • Male-to-Female ratio 1.3:1 • 79% of children diagnosed by age 4 • 97% of cases diagnosed before age 10

  34. Etiology4 • Chromosome #1 • Deletion/rearrangement on short arm of C’some 1 • Amplification of n-myc oncogene • Inherited mutation + 2nd mutation after birth vs. 2 acquired mutations after birth

  35. Symptoms • Abdominal mass/distention • Uncontrolled eye movement if facial involvement • Changes in urination, diarrhea • Pain, limping, paralysis, weakness if bone marrow involvement • Fever • High BP and increased HR

  36. Staging5

  37. Treatment • Surgery • Chemotherapy • Radiation • Bone marrow transplant • Antibiotics • Supportive care • Continuous follow-up

  38. Prognosis6 • Depends on a variety of factors including age of pt. and stage of disease • Survival significantly better for children less than 1 year of age • N-myc amplification confers worse prognosis • Increased ploidy has better prognosis

  39. Survival6 • Patients risk stratified into 3 groups • 5-year survival by risk group: 1) Low Risk- 95% 2) Intermediate Risk- 85-90% 3) High Risk- 30-50%

  40. Back to S.R. • Chemotherapy: completing 4 of 6 cycles today • Surgery to remove tumor • Bone marrow transplant

  41. References 1. An Evidence-Based Approach to the Evaluation and Management of Hip Pain in Children. Pediatric Case Reviews, Volume 2:1; January 2002 • http://www.emedicine.com/med/topic2836.htm • http://www.okstate.edu/artsci/zoology/ravdb/3024.htm • Staging of Neuroblastoma at Imaging. Report of the Radiology Oncology Diagnostic Group 2002; Volume 223:1 (p. 168-175) • http://www.cancer.org/docroot/cri/content/cri_2_4_3x_how_is_neuroblastoma_staged_31.asp

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