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Children with brain and spinal tumours: an emerging team approach
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-assessment
Questions Question I
A ICyear old Asian girl presented with abdominal pain and gastro-oesophageal reflux. She had fasted for religious reasons for the past month, but in the week before admission she had returned to a normal diet. She has 5 brothers and 4 sisters and they are all well. She has been doing well at school and in the last 2 weeks had been prescribed Gaviscon by her GP.
Creatinine Glucose Ca2+ Phosphate Albumin Total Protein Alk. Phosphatase Haemoglobin White count Platelets
Here are her investigations: Na+ 140 mmol/l Kf 4.5 mmol/l Urea 4.2 mmol/l
63 umol/l
4.9 mmol/l 1.58 mmol/l 1.74 mmol/l 46 g/d1 73 g/d1 400 IUjl 13.9 g/d1 6.7 x log/1 209 x log/1
1. What is the diagnosis? 2. What further investigations would you do? 3. What treatment would you give?
Question 2
A 12-year old Caucasian boy was admitted with a 2-week history of vomiting. He had developed a large swelling in the neck 2 weeks before but over the last couple of days he said this had settled. He had lost his appetite in the last few days and his mother said he looked rather thin. He complained of being thirsty all the time. There had been a head injury 1 year ago and he had fractured his arm in the past. Examination showed a lump over his right elbow which has been diagnosed as a post-traumatic haematoma. His parents are separated and he has a brother and sister who are both well. The mother is hepatitis B surface antigen positive. Here are his initial investigations: Dipak Kaoaber, London. Road, Correspondence
Registrar in Paediatrics, Royal Berkshire Reading, RGl 5AN. and requests for offprints to DK.
Currenr Paediarrim (1992) 2, 245-246 Q’ 1992 Longman Group UK Ltd
Na+ K+ Urea Creatinine Glucose Ca2 + Phosphate Albumin Alk. Phosphatase Haemoglobin White Count
136 mmol/l 4.1 mmol/l 11.1 mmol/l 111 umol/l 5.9 mmol/l 3.58 mmol/l 0.98 mmol/l 45 g/d1 173 IU/l 12.4 g/d1 10.4 x log/l
What are the metabolic abnormalities? Why is he vomiting? What treatment would you give to correct his biochemical abnormalities? What two further investigations are necessary to make the diagnosis?
Hospital,
245
246
CURRENT PAEDIATRICS
Question 3 A 12-year old boy was playing golf with his friends and was knocked out by a stray golf ball which hit him on the left side of his head. He was only unconscious for a few seconds but he was seen in the casualty department anyway. He was examined and apart from a slight stammer, which his mother said he already had, a skull X-ray showed no fracture and he was discharged home. He presented to the paediatric department a couple of days later with inability to name objects which were placed in front of him (expressive dysphasia). He had no other neurological signs. 1. What abnormality is shown on his CATscan? 2. What is the single most important question you should have asked this boy in order to decide whether the scan explains his symptoms?
Figure Computerised
tomogram of the brain.
Answers Answer 1 1. Metabolic bone disease (rickets). Dietary vitamin D deficiency is the most likely cause in this girl, so a dietary history is important. 2. X-rays of the distal ends of long bones; plasma 25hydroxy Vitamin D, check urine for aminoaciduria. 3. Vitamin D analogues i.e. Vitamin D2 (calciferol)
5000 units (125 mg) once daily for 4-6 weeks, or (1,25-dihydroxycholecalciferol (calcitriol)). Careful biochemical monitoring of plasma calcium and phosphate is advised to avoid toxicity, as well as a follow up X-ray after completion of treatment to confirm complete resolution.
Answer 2 Hypercalcaemia; hypophosphataemia; dehydration; pre-renal failure. Hypercalcaemia is rare in children, and should normally be confirmed on 2 or 3 fasting samples before full investigations commence. Recognised causes are parathyroid hyperplasia/adenoma, Vitamin D intoxication, and malignancy; the latter due to ectopic hormone production. Hypercalcaemia itself and an underlying malignancy.
with normal (0.9%) saline 3. Hyperhydration (4-51/mR2); frusemide intravenously; etidronate or pamidronate. 4. Biopsy of lump in arm; Computerised tomogram of the neck, arm and body. In fact this boy had a rhabdomyosarcoma originating in his right elbow and this tumour is associated with production of a parathyroid hormone like substance which accounts for his biochemical abnormalities.
Answer 3 1. This computerised tomogram of the brain (unenhanced) shows an area of high attenuation in the left parietal area compatible with an intracranial bleed.
2. He should be asked whether he is left or right handed, as this will lead to localisation of the pathology to the hemisphere where Broca’s speech area is located.
-assessment
Questions Question I
A ICyear old Asian girl presented with abdominal pain and gastro-oesophageal reflux. She had fasted for religious reasons for the past month, but in the week before admission she had returned to a normal diet. She has 5 brothers and 4 sisters and they are all well. She has been doing well at school and in the last 2 weeks had been prescribed Gaviscon by her GP.
Creatinine Glucose Ca2+ Phosphate Albumin Total Protein Alk. Phosphatase Haemoglobin White count Platelets
Here are her investigations: Na+ 140 mmol/l Kf 4.5 mmol/l Urea 4.2 mmol/l
63 umol/l
4.9 mmol/l 1.58 mmol/l 1.74 mmol/l 46 g/d1 73 g/d1 400 IUjl 13.9 g/d1 6.7 x log/1 209 x log/1
1. What is the diagnosis? 2. What further investigations would you do? 3. What treatment would you give?
Question 2
A 12-year old Caucasian boy was admitted with a 2-week history of vomiting. He had developed a large swelling in the neck 2 weeks before but over the last couple of days he said this had settled. He had lost his appetite in the last few days and his mother said he looked rather thin. He complained of being thirsty all the time. There had been a head injury 1 year ago and he had fractured his arm in the past. Examination showed a lump over his right elbow which has been diagnosed as a post-traumatic haematoma. His parents are separated and he has a brother and sister who are both well. The mother is hepatitis B surface antigen positive. Here are his initial investigations: Dipak Kaoaber, London. Road, Correspondence
Registrar in Paediatrics, Royal Berkshire Reading, RGl 5AN. and requests for offprints to DK.
Currenr Paediarrim (1992) 2, 245-246 Q’ 1992 Longman Group UK Ltd
Na+ K+ Urea Creatinine Glucose Ca2 + Phosphate Albumin Alk. Phosphatase Haemoglobin White Count
136 mmol/l 4.1 mmol/l 11.1 mmol/l 111 umol/l 5.9 mmol/l 3.58 mmol/l 0.98 mmol/l 45 g/d1 173 IU/l 12.4 g/d1 10.4 x log/l
What are the metabolic abnormalities? Why is he vomiting? What treatment would you give to correct his biochemical abnormalities? What two further investigations are necessary to make the diagnosis?
Hospital,
245
246
CURRENT PAEDIATRICS
Question 3 A 12-year old boy was playing golf with his friends and was knocked out by a stray golf ball which hit him on the left side of his head. He was only unconscious for a few seconds but he was seen in the casualty department anyway. He was examined and apart from a slight stammer, which his mother said he already had, a skull X-ray showed no fracture and he was discharged home. He presented to the paediatric department a couple of days later with inability to name objects which were placed in front of him (expressive dysphasia). He had no other neurological signs. 1. What abnormality is shown on his CATscan? 2. What is the single most important question you should have asked this boy in order to decide whether the scan explains his symptoms?
Figure Computerised
tomogram of the brain.
Answers Answer 1 1. Metabolic bone disease (rickets). Dietary vitamin D deficiency is the most likely cause in this girl, so a dietary history is important. 2. X-rays of the distal ends of long bones; plasma 25hydroxy Vitamin D, check urine for aminoaciduria. 3. Vitamin D analogues i.e. Vitamin D2 (calciferol)
5000 units (125 mg) once daily for 4-6 weeks, or (1,25-dihydroxycholecalciferol (calcitriol)). Careful biochemical monitoring of plasma calcium and phosphate is advised to avoid toxicity, as well as a follow up X-ray after completion of treatment to confirm complete resolution.
Answer 2 Hypercalcaemia; hypophosphataemia; dehydration; pre-renal failure. Hypercalcaemia is rare in children, and should normally be confirmed on 2 or 3 fasting samples before full investigations commence. Recognised causes are parathyroid hyperplasia/adenoma, Vitamin D intoxication, and malignancy; the latter due to ectopic hormone production. Hypercalcaemia itself and an underlying malignancy.
with normal (0.9%) saline 3. Hyperhydration (4-51/mR2); frusemide intravenously; etidronate or pamidronate. 4. Biopsy of lump in arm; Computerised tomogram of the neck, arm and body. In fact this boy had a rhabdomyosarcoma originating in his right elbow and this tumour is associated with production of a parathyroid hormone like substance which accounts for his biochemical abnormalities.
Answer 3 1. This computerised tomogram of the brain (unenhanced) shows an area of high attenuation in the left parietal area compatible with an intracranial bleed.
2. He should be asked whether he is left or right handed, as this will lead to localisation of the pathology to the hemisphere where Broca’s speech area is located.