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
Ist 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

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 106
WBC 1 x 106, 100% lymphocytes
glucose of 4.7 mmol/L
protein 0.11 g/L
(-) Pandy’s

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

9. COURSE IN THE WARDS 7TH 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. 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

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

12. 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

13. 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

14. 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

15. 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

16. DIFFERENTIAL DIAGNOSIS: HEMANGIOBLASTOMA
RULED IN due to:
RULED OUT due to:
Long history of headache (1 year)
Vomiting
Predominant in males
presence of some cerebellar signs
low incidence in the pediatric age group
seen as a hypodense mass with associated hydrocephalus

17. DIFFERENTIAL DIAGNOSIS: CRYPTOCOCCOMA
RULED IN due to:
RULED OUT due to:
-Intermittent headache
-projectile vomiting
CSF analysis of the patient which revealed 100% lymphocytes
hyperdense lesion upon CT scan
CSF analysis was unremarkable for a cryptococcal etiology
improvement with this disease is noted with administration of IV Amphotericin B which was not given to the patient

18. 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

19. PLAN: Treatment Surgery Glucocorticoid treatment
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

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