{Pediatric Zebras
Rene Y. McNall-Knapp, MD, FAAPPedatric Hematology/Oncology, OUHSC
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
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 - ?
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
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
Treatment and Results
Started on induction therapy for standard risk ALL
On day 29 was in remission
Continues on chemotherapy
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
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
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
Case #2
2nd Visit History – continues
to have daily vomiting, also acting as if hurting inactive, losing milestones
PE – weight loss, sleepy
Labs/Imaging – Assessment/Plans -
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
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
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
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
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 betterRed 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 steroidsRed 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
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
cystRed light zebra symptoms
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 ultrasoundSigns to collect yourself