1. Rene Y. McNall-Knapp, MD, FAAP Pedatric Hematology/Oncology, OUHSC
Pediatric Zebras
Rene Y. McNall-Knapp, MD, FAAP
Pedatric Hematology/Oncology, OUHSC

5. Telling the Difference
Keep worst possible diagnosis (UGLY ZEBRA) in mind
Family, patient, caregivers partner in care
Expected course of disease
May take more than one visit
Bad things don’t get better on their own
Stay humble
Telling the Difference

6. Day 1
4 y.o. boy presents with back and leg pain for 2-3 days
History – no fever, hurting mostly at night, usually very active
Physical – unremarkable, scattered bruises of various ages
Labs/Imaging - ?
Case study #1

7. Case Study #1 Visit 2 WBC 4.4K (80% lymphs) Hemoglobin 5.2 g/dL
History – pain worsening, not walking, lethargy, bruising, fever
PE – bruising, pallor, lymphadenopathy
Labs/Imaging
WBC 4.4K (80% lymphs)
Hemoglobin 5.2 g/dL
Platelets 10K
Case Study #1

8. Diagnosis Leukemia – in this case ALL
ALL/AML – most common cancer in childhood
Presenting symptoms, findings
Anemia – pallor, fatigue
Thrombocytopenia – bruising, bleeding
Leukocytopenia – infections, thrush, fever
Adenopathy – mediastinal, peripheral
Splenomegaly
Bone pain
Leukemia cutis
Diagnosis

9. Started on induction therapy for standard risk ALL
On day 29 was in remission
Continues on chemotherapy
Treatment and Results

10. Importance of identifying zebras
Cancer is #1 disease killer in children
Cancer is diagnosed in 1:300 boys and 1:330 girls before 21
Stage at diagnosis has dramatic effect on prognosis (morbidity and mortality)
75% cure for all children walking in door
Importance of identifying zebras

11. Challenges of delay in diagnosis
Imagine if you didn’t catch it on visit 2
Patient worsened and worsened over next 2 weeks
Presents to local ER
Codes due to severe anemia and infection
Revived but multisystem organ dysfunction and disseminated Aspergillus
Must treat leukemia in face of all of this
Challenges of delay in diagnosis

12. 1st visit
Almost 2 y.o. girl with complaint of vomiting for last month
No rhyme or reason to the vomiting
PE – small, fluid behind TM, otherwise unremarkable
Labs/imaging
Assessment and plan – otitis, amoxicillin, RTC 2 weeks for ear recheck
Case #2

13. 2nd Visit
History – continues to have daily vomiting, also acting as if hurting inactive, losing milestones
PE – weight loss, sleepy
Labs/Imaging –
Assessment/Plans -
Case #2

14. Presents to ER 2 weeks later because parents worried she might have a parasite
History – vomiting everything, lost 1/3 of her weight
Physical – emaciated, lethargic
Labs/Imaging – normal labs, US abdomen and Xray normal
Admitted to hospital for observation
That night stopped breathing – Code Blue
Revived and imaging done
Case #2 – Imagine If

15. Diagnosis Brain Tumor (Specifically Medulloblastoma)
2nd most common cancer in childhood
Prognosis depends on type and stage of diagnosis, surgical resection
Presenting symptoms – common for posterior fossa
Nausea/vomiting
Headache
Head tilt
Ataxia
Lethargy
Double vision
Diagnosis

16. Other Symptoms of Brain Tumors
Infants – macrocephaly, sunset eyes, loss of milestones, wasting
Seizures – not febrile seizures
Abnormal eye movements or looking through peripheral vision
Delayed or precocious puberty
Abnormal growth
Other cranial nerve palsies – drooling, aspirating, facial droop
Other Symptoms of Brain Tumors

17. Approaches to zebra symptoms
First – do no harm
Least invasive/radioactive test you can do to reassure yourself
Let the kid keep some of his own blood
Second – build rapport with family for close follow-up
Third – act deliberately using history and physical as your guide
Hint – there are algorithms out there to help!
Approaches to zebra symptoms

18. Red light zebra symptoms
Hypertension – should test at least annually and at every sick visit
Varies by age and height
Renal tumors disease, adrenal tumors and disease, coarctation of the aorta (arm > leg), others
W/U – H&P, UA, CMP, renal US
Horses – essential hypertension
Fever > 5 days
101 F
Leukemia, Kawasaki, unusual infections
W/U – H&P, CBC, appropriate cultures
Horses – I don’t know what but Zithromax will make it better
Red light zebra symptoms

19. Red light zebra symptoms
Eye – abnormal eye movements, proptosis, white reflex
Brain tumor, retinoblastoma, metastatic disease, rhabdomyosarcoma, orbital cellulitis
W/U – urgent ophthalmology referral, MRI brain/orbit
Horses – normal for baby, conjunctivitis
Adenopathy
>1 cm all except inguinal (>1.5 cm) and supraclavicular (any)
Leukemia, lymphoma, EBV, other infections, abdominal malignancy (Virchow’s node)
W/U – CBC, CMP, uric acid, LDH, CXR, response to antibiotics (if appropriate case), biopsy
Horses – common infections
Warning – do not give steroids
Red light zebra symptoms

20. Red light zebra symptoms
Wheezing, shortness of breath
Foreign body, mediastinal mass, vascular ring
W/U – H&P, CXR
Warning – again steroids!
Abdominal mass
Renal disease, tumors, benign lesions, severe constipation
W/U – H&P, Xray or abdominal US
Red light zebra symptoms

21. Red light zebra symptoms
Bone or joint pain
Infection, leukemia, sarcomas, metastatic lesions
W/U – H&P, CBC, Xray entire bone, consider bone scan
Horses – growing pains, injury
Soft tissue mass
Sarcoma
W/U – image (MRI) then excisional biopsy
Horses – lipoma, ganglion cyst
Red light zebra symptoms

22. Signs to collect yourself
Poor growth – growth charts essential
Brain tumor, Turner’s syndrome, other syndromes
W/U – H&P, ?endocrinology referral, ?imaging
Horses – normal for patient
Delayed or precocious puberty
Testicular mass
Testicular cancer
W/U – H&P, testicular ultrasound
Signs to collect yourself