RODENAS, CARISSA B.

CSS GROUP # 10

Summary of the Pertinent Information of the Case:

This is a case 6-month old female born to a 44-year old G6P5 (5005) mother, coming in with a chief
complaint of abdominal enlargement which has been progressively enlarging over the course of 3 months. The
abdomen was firm and non-tender and no associated symptoms such as fever, changes in bowel movements,
jaundice and vomiting was reported. The patient was brought to the local health center for consult 2 weeks prior
to admission where she was given multivitamins and was advised to seek consult at a tertiary hospital, but they
did not comply. No other symptoms were reported aside from the abdominal enlargement and she was noted to
have good suck, cry, activity, regular bowel movement, and adequate urine output. The patient then started
having dark green, formed, non-bloody stool, along with abdominal enlargement 2 days prior to admission, and
these prompted their consult at the Philippine General Hospital.
Review of systems showed that the patient has good suck, cry, and somatic activity with no remarkable
symptoms such as seizures, intermittency in feeding, bleeding, jaundice, edema, cyanosis, difficulty in
breathing, and increased sleeping time.
Prenatal history showed that her mother had regular check-ups and she was prescribed with
multivitamins and ferrous sulfate in which she was compliant.
Natal history that the patient was born term via caesarean section due to non-reassuring fetal status at a
district hospital. Her APGAR score was unrecalled and newborn screening was not done. Her mother was
advised to seek consult at a tertiary hospital due to the Down syndrome features of the patient but they did not
comply. Post-delivery course was unremarkable.
For nutrition history, patient was breastfed for the first 2 weeks of her life and was switched to formula
milk. She was fed approximately 5 oz., 3x-4x a day, and she had good suck with no post-prandial vomiting,
food allergy, or intermittency in feeding.
The patient was said to receive complete vaccination except for Measles vaccination.
Upon physical examination, patient was awake, has good suck, cry, and somatic activity, and was not
in cardiorespiratory distress. Vital signs showed that the patient was tachycardic, hypotensive, non-tachypneic,
and with low grade fever. For anthropometrics, head circumference was 37.5 cm, chest circumference was 39
cm, abdominal circumference at the widest was 46.5, and 41 cm at the level of umbilicus, weight was 5.5 kg,
and height was 59 cm. She had pale palpebral conjunctivae with anicteric sclera, flat facies, low nasal bridge,
low set ears, upslanted palpebral fissure, protruding tongue, ans vermillion tinted upper lip. Respiratory and
cardiac findings were unremarkable. Her abdomen was globular, firm, and tense, no abdominal wall defects,
liver edge was 6 cm below the right subcostal margin at MCL. Mass was palpated at the right hemiabdomen
extending to left hemiabdomen, measuring 12x8 cm. Examination on extremities showed plantar crease between
the 1st and 2nd toe. Neurologic examination showed hypotonia.

ONE Primary Working Impression with Rationale: GASTRIC TERATOMA

Gastric teratoma was considered as the primary working impression because of the patient’s age (6
months old), palpable abdominal mass which was approximaately 12x8 cm located at right hemiabdomen
extending to the left hemiabdomen, anemia based on her pale conjunctiva and haemoglobin level of 53,
hypotension, melena, and coffee ground material coming out of the orogastric tube.
Teratoma is said to be the most common tumor among germ cell neoplasms in children with most of
the cases occurring in children before one year of age. In infancy and early childhood, the most common
location of teratoma is extragonadal a compared to that of in late childhood and adults where it is more common
in the gonads (Gobel et. al, 1998). The usual presentations of teratoma are palpable mass or abdominal
distension, followed by respiratory distress, vomiting, melena, and hematemesis. According to Valenzuela-
Ramos et al. (2010), the combination of abdominal mass with upper digestive bleeding, which are both
presented by the patient, highly suggest the presence of this tumor.
One of the theories that explain the origin of teratoma is Teilium’s theory wherein primordial germ
cells that migrate abnormally undergo malignant transformation, leading to the formation of germ cell tumors.
These tumors are said to have the tendency to migrate to midline structures, one of which is the stomach. Once
the teratoma is formed, it will form a palpable mass. As it progressively increases in size, the stomach will also
increase in size, leading to the abdominal distension of the patient. The transmural growth of the tumor in the
stomach will also result to the disruption of the mucosa, leading to upper gastrointestinal bleeding which will
present as melena and hematemesis. This bleeding is also the cause of the patient’s anemia and hypotension.

Differentials with Rationale:

1. Hepatoblastoma – it was considered because of the patient’s age and her presentation such as
abdominal enlargement, palpable mass which is predominantly on the right side, hepatomegaly, and
melena and hematamesis which indicate the presence of gastrointestinal bleeding. It was less likely
because of the patient’s gender as hepatoblastoma is more commonly found in males. The patient also
did not present with the usual presentation of hepatoblastoma such as jaundice pruritus, loss of appetite,
weight loss, enlarged veins on the abdomen, fever, thrombocytopenia, and elevated ALT.
2. Wilm’s Tumor – it was considered because of the patient’s enlarging abdomen, palpable mass in the
right hemiabdomen extending to the left hemiabdomen, pale palpebra and pallor. It is also the most
common renal malignancy in children with most of its cases diagnosed before the age of 5. Patient’s
with Wilm’s tumor appears to be well, like in the early course of the patient’s disease. Also, it is known
to be associated with congenital syndromes. It was less likely because Wilm’s tumor cannot explain the
presence of gastrointestinal bleeding. Also, the patient did not present with hematuria or fever.
3. Gastric Lymphoma – it was considered because the usual presentation of gastric lymphoma is
gastrointestinal bleeding which manifests as hematemesis or melena, which are both present in the
patient. Other symptoms of gastric lymphoma include abdominal enlargement and palpable abdominal
mass which are also present in the patient. Lymphoma is also associated with Down syndrome in which
the patient seems to have. It was less likely because the patient did not present with other symptoms
such as fever, weight loss, and night sweats.

Concise Diagnostic Plan to confirm your PWI :

1. CBC - to determine the presence and type of anemia since the patient has pale palpebral conjunctiva
2. Biopsy - to assess the histology of the mass present in the patient
3. Imaging (Abdominal radiograph, UTZ, CT and MRI) - needed to evaluate the severity or extent of the
mass; it is also needed to visualize if there is cyst, calcification, or fats that are highly suggestive of
teratoma

Concise Management Plan for typical cases of your PWI:

1. Partial gastrectoma or total gastric resection – depending on the size and extent of the mass
2. Chemotherapy – done to patients with malignant extragonadal germ cell tumor