An unusual cause of neonatal apnoea (Discussion and Diagnosis)

Abstract

The Case Presentation can be found on page 772. DISCUSSION While apnoea is a common problem in preterm infants, in term neonates, apnoea should always raise concern for a pathologic cause. This differential diagnosis of apnoea in the term neonate is broad. As episodes are usually brief, it can be difficult to classify occurrences as central, obstructive or mixed. Initial work-up should focus on identifying potentially treatable, life-threatening conditions such as sepsis, metabolic disturbances, accidental or intentional poisoning, abusive head injury, seizures and cardiovascular causes. To my knowledge, neonatal apnoea has not been previously described in the literature as presentation of gastric teratoma. Although the overall prevalence of neonatal teratomas is unknown, themost common form, sacrococcygeal teratoma, occurs once in every 14,900 live births (1). While rare, neonatal teratomas represent the most common congenital tumours and comprise 35% of neonatal tumours (2). The majority of teratomas in children and adults arise from gonadal sites; however, teratomas in neonates most commonly arise from extra-gonadal sites such as the sacrococcygeal area and mediastinum. Gastric teratomas account for less than one percentage of neonatal teratomas (3). To date, there are nine reported cases of neonatal gastric teratomas in the literature. Clinical presentations described by previous authors include severe anaemia, gastrointestinal bleeding, abdominal distension and respiratory distress (4–6). Neonatal teratomas are usually benign; therefore, complications are related to mass effect rather than malignant potential. Surgical resection is curative, but complete resection is often challenging due to the location of these tumours. Alpha-fetoprotein (AFP) should be followed as a marker of incomplete resection or recurrence (7). Interpretation of serum AFP in the neonatal period is challenging as levels are normally elevated at birth and decline over the first year of life. In this patient, serum AFP was 3225 ng/mL prior to resection, 40.5 ng/mL at 2 months and 1.5 ng/mL at 1 year of age. Yearly MRI has not shown evidence of recurrence. The patient is now 5-year old. He is growing appropriately and performing well in school.