ATYPICAL MANIFESTATIONS OF PEDIATRIC CANCER

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ATYPICAL MANIFESTATIONS OF PEDIATRIC CANCER
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Diagnosis of Childhood Cancer

• Childhood cancer is often difficult to diagnose
  in early stages because it may mimic a variety of
  common childhood diseases.
• A general pediatrician often has reluctance to
  suggest the diagnosis of cancer because it is
  relatively rare and because of the ominous
  implications to the family.

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Common Manifestations of Childhood Cancer

• Persistent fever with weight loss
• Headaches, morning vomiting
• Lymphadenopathy
• Bone pain
• Abdominal mass
• Mediastinal mass
• Pancytopenia
• Bleeding

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Atypical Manifestations of Childhood Cancer

• About 10-15 of cases present with unusual
  manifestations and make the diagnosis even more
  difficult.
• The most common tumor presenting with unusual
  manifestations is neuroblastoma.

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Neuroblastoma

• Horners syndrome
• Leukemoid reaction
• Myasthenia gravis
• Heterochromia

• Chronic diarrhoea
• Opsomyoclonus
• Failure to thrive
• Cushings syndrome

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Acute Leukemia

• Rheumatoid arthritis
• Hypereosinophilia
• Aplastic anemia
• Virus associated hemophagocytic syndrome

• Hypercalcemia
• Pulmonary nodules
• Pericardial effusion
• Clitorism/Priapism

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Hodgkins Disease

• Nephrotic syndrome
• Autoimmune hemolytic anemia
• Dermatomyositis
• Acute dysautonomia
• Central pontine myelinolysis

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Case 1-Gastroesophageal reflux with failure to
thrive

• An infant presented with failure to thrive
  associated with recurrent vomitings.
• She was investigated by pediatric
  gasteroenterology and found to have
  gastroesophageal reflux by pH probe test.
• The patient had placement of a percutaneous
  gastric tube treated with anti-reflux measures
  however, there was no weight gain.
• She was then posted for fundoplication.

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• MRI brain was suggested by the pediatric
  oncologist prior to surgery to rule out a
  diencephalic syndrome.
• MRI showed presence of a cervico-medullary tumor.
  
• Tumor was felt to be inoperable. Patient improved
  on chemotherapy for low grade gliomas
  (carboplatinum and vincristine).

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Message

• Common diseases if unresponsive should prompt a
  physician to look for alternate diagnosis.

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Case 2- Paraplegia

• A 5-year old child presented with sudden onset
  paraplegia.
• Clinical examination suggested upper motor neuron
  involvement of lower extremities.
• MRI spine showed an infarct in the spinal cord.
• A CBC confirmed the diagnosis of acute myeloid
  leukemia with a WBC count of gt 500,000/mm3.
• High WBC count had resulted in thrombosis of
  artery of Adamkeveicz.

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Message

• CBC with a careful examination of peripheral
  blood smear is a simple test which may be useful
  in many diverse clinical situations and clinch
  the diagnosis.

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Case 3- ITP

• A 4 year old boy presented with oral bleeding,
  melaena and petechial rash.
• CBC showed Hb 9g/dL WBC 8,400/mm3 and platelet
  10,000/mm3. Peripheral smear did not show any
  blasts.
• A diagnosis of acute ITP was made and treated
  with wysolone.

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• Patients bleeding was stopped. Three months
  later patient again presented with bleeding
  manifestations.
• CBC showed a high WBC count with presence of
  lymphoblasts.
• Patient was started on therapy but had a bone
  marrow relapse while on therapy and died.

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Message

• Bicytopenia or associated normocytic normochromic
  anemia in association with thrombocytopenia needs
  a bone marrow examination before labeling a
  patient as acute ITP.
• Peripheral smear in ITP needs a careful
  examination for large platelets.

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Case 4- Chronic liver disease

• A 2-year old child presented with 3 month history
  of jaundice and was found to have
  hepatosplenomegaly.
• Patient was investigated for chronic liver
  disease and diagnosed as sclerosing cholangitis
  by liver biopsy.
• On follow-up, patient developed polyuria with
  polydipsia.
• MRI brain showed presence of lesion in sella
  tursica.

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• While waiting for the brain biopsy, patient
  developed paronychia like lesions in all the
  nails. This was unresponsive to antibiotics.
• Biopsy of the nail lesion established a diagnosis
  of Langerhans cell histiocytosis.
• Patient was started on chemotherapy on which his
  nail lesions have improved, although the chronic
  liver disease has persisted.

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Message

• Sclerosing cholangitis is an uncommon
  manifestation of histiocytosis.
• Atypical manifestations of a particular disease
  may precede the typical manifestations.

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