CAGAYAN STATE UNIVERSITY

COLLEGE OF MEDICINE
Carig Campus, Tuguegarao City

PEDIATRICS WARD

Submitted by: Quinan, Reedon

Soriano, Archelle Celestine
Villanueva, Joshua

3rd Year Medical Students- MIDTERM GROUP

Submitted to: GRANDELEE TAQUIQUI, MD

PEDIA LABORATORY PRECEPTOR

PATIENT PROFILE
NAME : MK
AGE : 7 y/o
ADDRESS : Alcala, Cagayan
DATE OF ADMISSION : April 16 , 2020
CHIEF COMPLAINT : Pallor

HEALTH HISTORY

HISTORY OF PRESENT ILLNESS:

3 days prior to admission, the patient was noted to with pallor. Complete blood count revealed low
hemoglobin and white blood cell count, and was admitted at Divine Mercy hospital for blood transfusion. The
patient condition was improved and was discharged but then advised to admit at CVMC for work-up.

PAST MEDICAL HISTORY:

The patient was previously admitted last March 2020, due to nutritional anemia (IDA) in which she was
transfused with 1 unit of packed RBC, discharge and lost to follow-up.
PAST MEDICAL HISTORY:
The patient is the 3rd child of 4 siblings and she is grade 1 pupil. Her father, 31 years old is a tricycle
driver while her mother 29 years old is an overseas Filipino worker. The patient has no history of exposure to
fertilizer, chemicals nor radiation.
FAMILY HISTORY
The patient’s family has a history of cancer and hypertension.

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 REVIEW OF SYSTEMS

Constitutional: (-) weight loss

(-) loss of appetite
HEENT:
▪ Head: (-)headache,(-) slight dizziness (-) neck pain
▪ Eyes: No changes in visual field, blurring and pain
▪ Ears: (-) hearing impairment, (-) otalgia, (-) otorrhea
▪ Nose: No nasal discharge and congestion
▪ Throat: No difficulty in swallowing, no ulceration, bleeding and hoarseness
Integumentary System :(-) pruritus, (-) rash,
Central Nervous System :(-) seizure, (-) drowsiness, (-) confusion
Respiratory System :(-) cough, (-) colds, (-) hemoptysis, (-) dyspnea
Cardiovascular System: (-) chest pain, no palpitations
Gastrointestinal System :(-) vomiting, (-) hypogastric pain, (-) diarrhea, (-) constipation, (-) nausea
Genitourinary System: (-) hematuria, (-) nocturia, (-) polyuria, (-) bilateral flank pain, (-) difficulty/ pain in
urinating
Musculoskeletal System: (-) body weakness, (-) paralysis on upper and lower extremities (-) muscle pain
Endocrine system: (-) sweating, (-) fever, (-) polydipsia, (-) polyphagia
PHYSICAL EXAM
General: The patient is conscious, coherent and not in cardiorespiratory distress.

Vitals signs:
Temperature: 36.4 C
BP: 90/60
Pulse Rate: 91 beats per minute
Respiratory rate: 19 breaths per cycle

Anthropometric measurements:
Weight: 19 kg
Skin: (+) pallor; (-) warm to touch, (-) rashes, (-) cyanosis; (-) jaundice; (-) petechiae, (-) hematoma, (-) scars,
HEENT:
Head: symmetrical facial features, no palpable mass, hair with normal texture and equally distributed
Eyes: normal relationship of eyelids to the eyeballs, eyes not sunken, anicteric sclerae, pink palpebral
conjunctivae, pupil size is approximately 2-3mm
Ears: mobile pinna without masses or tenderness, no discharge
Nose: symmetrical nose, midline nasal septum, equal size and shape of the nares, no discharge
Oral cavity: moist, no lesions, masses, tonsillo-pharygneal congestion
Neck: no palpable thyroid mass
Chest and Lungs: (-) lesions or masses, (-) defect on chest wall, symmetrical on chest expansion, (-) chest
retraction, (-) tenderness, resonant on percussion, clear equal breath sounds, (-) wheezes
Heart: Adynamic precordium, PMI at 5th ICS, left MCL, Normal rate and regular rhythm, no murmur
Lymphatics: (+) Multiple lymphadenopathy at the cervical, submandibular and left inguinal area
Abdomen: flat, no abdominal mass, hypoactive bowel sounds, soft, tympanic upon percussion, nontender
Extremities: No pitting edema, no gross deformities, non-cyanotic, with a capillary refill time of 1-2 seconds,
strong equal peripheral pulses, good muscle tone

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 SALIENT FEATURES
A 7 year old female patient presents with:
- Pallor
- low hemoglobin and white blood cell count
- multiple lymphadenopathy at the cervical, submandibular and left inguinal area
- family history of cancer

INITIAL IMPRESSION
T/C HODGKIN LYMPHOMA

DIFFERENTIAL DIAGNOSIS
ACUTE LYMPHOBLASTIC LEUKEMIA
Acute lymphoblastic leukemia (ALL) is characterized by replacement of normal marrow elements with
malignant lymphoblast (cancerous cells derived from lymphoid precursor cells).The leukemia are the most
common malignant neoplasms in childhood, accounting for approximately 31% of all malignancies that occur
in children younger than 15 year of age. Acute lymphoblastic leukemia (ALL) accounts for approximately
77% of cases of childhood leukemia.
RULE IN RULE OUT
(+) pallor (-) Fever
(+) Family history of cancer (-) Bone and joint pain
(+) low hemoglobin count (+) low white blood cell count
(+) Lymphadenopathy (-) purpuric/petechial skin lesions
From information on the presence of history of cancer in the family and multiple lymphadenopathy during
the noted during physical examination, ALL is primarily considered in this case. Low hemoglobin count and pallor
are additional data that can be considered in which can also be seen in patient with ALL.
However, some important symptoms in considering the diagnosis such as fever, bone and joint pain, high
white blood cell count (in which the patient in this case has low white blood cell count) and presence of
purpuric/petechial skin lesions are not noted in the patient. Further assessment such as bone marrow smears, to
examine the presence of blast cells, are needed to finally rule-out this differential.
HISTIOCYTIC NECROTIZING LYMPHADENITIS/KIKUCHI-FUJIMOTO DISEASE
Kikuchi-Fujimoto disease is a rare, usually self-limiting cause of lymphadenitis that commonly reported
in patients of Asian heritage.

RULE IN RULE OUT

(+) cervical lymphadenopathy (+) pallor
(+) low white blood cell count (+) low hemoglobin count

Histiocytic necrotizing lymphadenitis is considered as one of the differentials because of the presence of
cervical lymphadenopathy which is the common symptom of this condition. In addition to lymphadenopathy, low
WBC count is also noted in the patient. However, due to presence of pallor and low hemoglobin count this
condition is further ruled-out.
Further investigation in ruling-out the disease, such as measuring Erythrocyte-sedimentation rate and liver
enzyme level, must be needed. And most specially, the histologic examination of the must also include, to see

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the specific histologic features of this disease that includes the presence of necrosis with karyorrhexis, a histiocytic
infiltrate, crescentic plasmacytoid monocytes and an absence of neutrophils.
BURKITT LYMPHOMA
Burkitt Lymphoma (BL) or small noncleaved cell lymphoma characterized by the translocation and
deregulation of the c-myc gene on chromosome 8. It is a highly aggressive B cell lymphoma.

RULE IN RULE OUT

(+) cervical and submandibular lymphadenopathy (-) abdominal tenderness
(+) Low hemoglobin count (-) ecchymosis/ petechiae
(+) Low white blood cell count (-) Headache
(-) Visual impairment

Lymphadenopathy of the submandibular (most common part) and cervical is commonly noted in the
physical examination of a patient with Burkitt lymphoma. Bone marrow involvement can cause low levels of
blood cell counts. Due to massive involvement of different system of the body symptoms such as abdominal
tenderness, ecchymosis/petechiae and CNS irritation that can cause headache and visual impairment are
common in the patient with Burkitt lymphoma but not in patient with Hodgkin lymphoma.
Further investigation such as the use of CT imaging of the chest, abdomen and pelvis is highly
recommended to check the massive involvement of this condition and to help in ruling-out this differential.

CASE DISCUSSION
Hodgkin lymphoma (HL) is a malignant process involving the lymphoreticular system that account
for 6% of childhood cancers. Hodgkin lymphoma is characterized by the presence of multinucleated giant cells
known as Reed Sternberg cells or large mononuclear cell variants known as lymphocytic and histiocytic cells, in
a background of inflammatory cells.
The lymphatic system is part of the immune system. The clear fluid called lymph flows through lymphatic
vessels and contains infection-fighting white blood cells, known as lymphocytes. In Hodgkin lymphoma, B
lymphocytes start to multiply in an abnormal way and begin to collect in certain parts of the lymphatic system,
such as the lymph nodes. The affected lymphocytes lose the ability to fight infection. The most common symptom
of Hodgkin lymphoma is a painless swelling in a lymph node, usually in the cervical, axillary and inguinal regions.
EPIDEMIOLOGY
The worldwide incidence of Hodgkin lymphoma is approximately 2-4 new cases/100,000
population/year; there is a bimodal age distribution, with peaks at 15-35 year of age and again after 50 yr.
It is the most common cancer seen in adolescents and young adults, and the third most common in children younger
than the age of 15 yr. In developing countries, the early peak tends to occur prior to adolescence. A male:
female predominance is found among young children, but lessens with age. Infectious agents may be involved,
such as human herpesvirus 6, cytomegalovirus, and Epstein-Barr virus (EBV). The role of EBV is supported by
prospective serologic studies. Infection with EBV confers a 4-fold higher risk of developing HL and may precede
the diagnosis by years. EBV antigens have been demonstrated in HL tissues, particularly type II latent membrane
proteins 1 and 2, although EBV status is not thought to be prognostic of outcome.
CLINICAL MANIFESTATIONS
Patients commonly present with painless, nontender, firm, rubbery, cervical or supraclavicular
lymphadenopathy and usually some degree of mediastinal involvement. Clinically detectable
hepatosplenomegaly is rarely encountered. Depending on the extent and location of nodal and extra nodal
disease, patients may present with symptoms and signs of airway obstruction (dyspnea, hypoxia, and cough),
pleural or pericardial effusion, hepatocellular dysfunction, or bone marrow infiltration (anemia, neutropenia, or
thrombocytopenia). Disease manifesting below the diaphragm is rare and occurs in approximately 3% of all
cases. Systemic symptoms, classified as B symptoms that are considered important in staging, are unexplained
fever >38°C (100.4°F), weight loss >10% total body weight over 6 month, and drenching night sweats. Less
common and not considered of prognostic significance are symptoms of pruritus, lethargy, anorexia, or pain
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that worsens after ingestion of alcohol. Patients also exhibit immune system abnormalities that often persist
during and after therapy.
DIAGNOSIS
A. Evaluation of blood tests
▪ hematologic manifestations
▪ diagnostically abnormal circulating lymphoid cells or lymphocytosis
▪ Acute-phase reactants
▪ Liver function tests
▪ Renal function tests
▪ Serum uric acid
▪ Hypercalcemia
▪ Serum lactate dehydrogenase (LDH) levels
▪ Serum immunoglobulins
B. Evaluation of the chest
▪ Chest radiographs
▪ CT scans
▪ Thoracentesis and pleural biopsy
C. Evaluation of the abdomen and retroperitoneum
▪ CT scans
▪ Abdominal ultrasonography
▪ MRI
D. Nuclear scans
▪ Positron emission tomography (PET)
TREATMENT AND PATIENT MANAGEMENT
The treatment of pediatric HL is risk stratified and response based. Patients are classified into low‐,
intermediate‐, and high-risk groups. The stratifications generally consider stage, presence of B symptoms,
extranodal disease, and, in some stratification systems, bulk of disease.
Treatment consists of initial multiagent chemotherapy with a response evaluation done after 2–3 cycles. Many
of the agents in the MOPP and ABVD regimens originally developed to treat HL are still used. The concept of
non‐cross‐resistant chemotherapy incorporates several factors: each agent is individually active; the agents
differ in their mechanisms of action; and toxicities do not overlap. The agents in MOPP consist of nitrogen
mustard, vincristine (Oncovin), procarbazine, and prednisone; ABVD includes doxorubicin, bleomycin, vinblastine,
and dacarbazine. Etoposide has been used as an effective alternative to procarbazine to decrease gonadal
toxicity. The rapidity of the early response to chemotherapy has been used to determine extent of chemotherapy
and the need for involved‐field radiotherapy. Children with more advanced disease are also treated with
combined‐modality therapy.
PROGNOSIS
Prognostic factors and early-stage disease have an event-free survival (EFS) of 85-90% and an overall
survival (OS) at 5 year of >95%. Patients with advanced-stage disease have slightly lower EFS (80-85%) and
OS (90%), respectively, although OS has approached 100% with dose intense chemotherapy. Prognosis after
relapse depends on the time from completion of treatment to recurrence, site of relapse (nodal vs extranodal),
and presence of B symptoms at relapse. Patients whose disease relapses >12 months after chemotherapy alone
or combined modality therapy have the best prognosis, and their relapses usually respond to additional
standard therapy, resulting in a long-term survival of 60-70%. A myeloablative autologous stem cell
transplantation in patients with refractory disease or relapse within 12 months of therapy results in a long-term
survival rate of only 40-50%. Allogeneic stem cell transplantation has shown promise in patients with poor risk
features at relapse/progression.

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PATHOPHYSIOLOGY

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