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

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<ul><li> Slide 1 </li> <li> { Pediatric Zebras Rene Y. McNall-Knapp, MD, FAAP Pedatric Hematology/Oncology, OUHSC </li> <li> Slide 2 </li> <li> Slide 3 </li> <li> Slide 4 </li> <li> Slide 5 </li> <li> 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 dont get better on their own Stay humble </li> <li> Slide 6 </li> <li> Case study #1 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 - ? </li> <li> Slide 7 </li> <li> Case Study #1 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 </li> <li> Slide 8 </li> <li> 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 </li> <li> Slide 9 </li> <li> Treatment and Results Started on induction therapy for standard risk ALL On day 29 was in remission Continues on chemotherapy </li> <li> Slide 10 </li> <li> 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 </li> <li> Slide 11 </li> <li> Imagine if you didnt 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 </li> <li> Slide 12 </li> <li> 1 st 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 </li> <li> Slide 13 </li> <li> 2 nd Visit History continues to have daily vomiting, also acting as if hurting inactive, losing milestones PE weight loss, sleepy Labs/Imaging Assessment/Plans - </li> <li> Slide 14 </li> <li> 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 </li> <li> Slide 15 </li> <li> Brain Tumor (Specifically Medulloblastoma) 2 nd 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 </li> <li> Slide 16 </li> <li> 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 </li> <li> Slide 17 </li> <li> 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 </li> <li> Slide 18 </li> <li> 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 &gt; leg), others W/U H&amp;P, UA, CMP, renal US Horses essential hypertension Fever &gt; 5 days 101 F Leukemia, Kawasaki, unusual infections W/U H&amp;P, CBC, appropriate cultures Horses I dont know what but Zithromax will make it better Red light zebra symptoms </li> <li> Slide 19 </li> <li> 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 &gt;1 cm all except inguinal (&gt;1.5 cm) and supraclavicular (any) Leukemia, lymphoma, EBV, other infections, abdominal malignancy (Virchows 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 </li> <li> Slide 20 </li> <li> Wheezing, shortness of breath Foreign body, mediastinal mass, vascular ring W/U H&amp;P, CXR Warning again steroids! Abdominal mass Renal disease, tumors, benign lesions, severe constipation W/U H&amp;P, Xray or abdominal US Red light zebra symptoms </li> <li> Slide 21 </li> <li> Bone or joint pain Infection, leukemia, sarcomas, metastatic lesions W/U H&amp;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 </li> <li> Slide 22 </li> <li> Poor growth growth charts essential Brain tumor, Turners syndrome, other syndromes W/U H&amp;P, ?endocrinology referral, ?imaging Horses normal for patient Delayed or precocious puberty Brain tumor, Turners syndrome, other syndromes W/U H&amp;P, ?endocrinology referral, ?imaging Horses normal for patient Testicular mass Testicular cancer W/U H&amp;P, testicular ultrasound Signs to collect yourself </li> <li> Slide 23 </li> </ul>