Endgames Case Report

Early morning headache with vomiting in a 5 year old boy

BMJ 2013; 346 doi: http://dx.doi.org/10.1136/bmj.f3315 (Published 29 May 2013) Cite this as: BMJ 2013;346:f3315
  1. Benjamin R T Jones, fifth year medical student1,
  2. Shelley A Renowden, consultant neuroradiologist2,
  3. Stephen P Lowis, MacMillan consultant in paediatric and adolescent oncology 3,
  4. Kathreena M Kurian, consultant neuropathologist, honorary senior lecturer4
  1. 1Bristol University Medical School, University of Bristol, Bristol BS8 1TH, UK
  2. 2Department of Neuroradiology, Frenchay Hospital, Bristol BS16 1LE, UK
  3. 3Department of Paediatric Haematology, Oncology, and BMT, Bristol Royal Hospital for Children, Bristol, UK
  4. 4Brain Tumour Research Group, Department of Neuropathology, Frenchay Hospital, Bristol, UK
  1. bjones7392{at}gmail.com

A 5½ year old boy presented with a 10 day history of progressively worsening early morning headache, with vomiting and subsequent development of slurred speech. Before this presentation his development had been normal, with no delay in developmental milestones or abnormality in vision. He was referred to the emergency department for an urgent magnetic resonance imaging (MRI) scan, which showed a tumour arising from the fourth ventricle with a maximum dimension of 3 cm. There was slight dilation of the fourth ventricle, but no hydrocephalus or obvious disease in the spine or leptomeninges.

He underwent craniotomy and gross total excision of the mass. Cytological examination of the cerebrospinal fluid showed no malignant cells. Histological examination of the tumour showed that it was a medulloblastoma, with large pale nuclei (high nuclear to cytoplasmic ratio), cell-cell wrapping, and a high mitotic rate. There were several foci of apoptosis but no sheets of necrosis. Molecular analysis of the tumour showed that the c-Myc and N-Myc genes were amplified. Chemotherapy was started in accordance with Children Cancer and Leukaemia Group guidelines. This involves high dose intensity chemotherapy followed by craniospinal hyperfractionated accelerated radiotherapy.

Questions

  • 1 What is the differential diagnosis for his initial presenting symptoms of early morning headache with vomiting?

  • 2 What tumours may occur in a child of this age, at this site?

  • 3 What do the histology and immunohistochemistry results suggest?

  • 4 How would you manage this patient?

  • 5 What are the long term complications of neurosurgery, chemotherapy, and radiotherapy in children?

Answers

1 What is the differential diagnosis for his initial presenting symptoms of early morning headache with vomiting?

Short answer

Although relatively short, the history of early morning vomiting and slurred speech suggests a neurological cause. Differential diagnoses include raised intracranial pressure, migraine, and viral meningitis. Lack of meningism or signs of sepsis suggest that raised intracranial pressure is the most likely cause.

Long answer

A 10 day history of early morning …

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