Neuroblastoma
Patient Presentation:
K.S. was a 12 month old male who presented to the pediatric clinic for a 1 year well-baby check-up. On review of his growth chart it was noted that he had not gained any weight since his 9-month visit and his height velocity had decreased. The patient’s mother reported that he eats a normal pediatric diet including all food groups and 3, 8-oz cups of whole milk plus 1 cup of water or diluted juice per day. K.S. was formula fed until 11 months and other than mild reflux at 2 months, had no history of feeding difficulties. The patient’s mother also reported a 6 month history of intermittent liquid stools about 5 times per week with hard formed stools in between. She denied hematochezia, melena, steatorrhea, or black or tan/clay colored stools. Typically no other symptoms accompanied the periods of loose stools. However, earlier that week, an episode of loose stools had been accompanied by a fever of 101.5 which was relieved with Tylenol®. K.S. was born at 35 weeks gestation via spontaneous vaginal delivery without complications or NICU stay. His mother reported no family history of GI disorders. Upon physical exam, K.S. was found to be playful, alert and appropriate for his age. His arms and legs appeared very thin and his abdomen was markedly distended. Initial light palpation of his abdomen revealed a crackle sensation. His abdomen was soft and non-tender with palpable deep and superficial masses. A significant mass was palpated 1-2 inches left lateral of his umbilicus. The physical exam was otherwise unremarkable.
Differential List:
Constipation, Infectious GI process, Malabsorptive process, Neuroblastoma
Diagnosis:
Laboratory tests:
CBC: Hgb 9.2g/dL, Hct 31%, CBC otherwise WNL
CMP: LDH 197units/L, CMP otherwise normal
Ferritin: 243ng/ml (Normal=142), Pre-Albumin: WNL
Urine catecholamines: VMA 72 μg/mg creatinine (Cr) (Normal 18), HVA 99 μg/mg creatinine (Cr) (Normal=23)
Fecal reducing substances: WNL, Fecal qualitative fat: WNL, Fecal leukocytes: WNL, Stool ova and parasites: WNL
Abdominal CT and biopsy confirmed diagnosis of stage III neuroblastoma
Treatment:
K.S. was admitted to the inpatient pediatric ward with the diagnoses of failure to thrive, chronic diarrhea, and abdominal mass. Once the diagnosis of neuroblastoma was confirmed with imaging and biopsy, a central line was placed and K.S. was started on a chemotherapy protocol which included carboplatin, cyclophosphamide and doxorubicin. He was also started on Septra ® for pneumocystis pneumonia prophylaxis and Zofran® and Benadryl® for treatment of chemotherapy induced nausea.
Outcome:
To date K.S. has tolerated chemotherapy treatments well. It is too early in the course of his treatment to determine its efficacy. In general, children diagnosed with stage III neuroblastoma under the age of 1 have a 5-year survival rate of approximately 80%.
Case created by Karen Sanchez, 2012.