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Pediatric Zebras

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

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Pediatric Zebras

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

  2. 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

  3. 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

  4. Visit 2 • 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

  5. 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

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

  7. 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

  8. 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

  9. 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

  10. 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

  11. 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

  12. 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

  13. 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

  14. 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

  15. 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

  16. 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

  17. 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

  18. 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

  19. 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 • Brain tumor, Turner’s syndrome, other syndromes • W/U – H&P, ?endocrinology referral, ?imaging • Horses – normal for patient • Testicular mass • Testicular cancer • W/U – H&P, testicular ultrasound Signs to collect yourself

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