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7 Year Old Male With 2 Months Of Progressive Left Sided Weakness

Introduction: Gliomas are the most common primary CNS tumors making up 50-60% of brain tumors inchildren Prognosis for gliomas depends on histologic grade and location of tumor Impingement on normalbrain tissue or increase in intracranial pressure is caused by either obstruction of CSF flow or by direct masseffect Symptoms can include lethargy, headache and vomiting Signs of slow growing CNS tumors can includeirritability, poor school performance and loss of developing milestones Most arise with no known underlyingrisk factor or disorder Case Presentation: 7-year-old male with no significant past medical history presented with left sided weakness that began 8 weeks prior to admission Initially mother noticed the patient to have anasymmetric smile Patient was seen by PCP and was referred to ophthalmology and neurology at that time 4weeks later, he was noted to have left arm weakness and difficulty writing with his left hand A week later hebegan having weakness in his left leg and was noticed to have increased instability Patient was reevaluated byPCP who instructed him to complete a 5-day course of steroids and follow-up with neurology On the day of admission he was seen by an outpatient neurologist using telemedicine due to COVID outbreak It was notedthe patient had left sided paralysis, a dilated left pupil, weakness of the left arm and leg with elevation Afterseeing the physical exam findings through a webcam, the neurologist suggested for the patient to have urgentevaluation in the emergency department CT brain with contrast revealed a heterogenous, complex mass inthe region of the right hypothalamus MRI brain showed mass that involved the right and left cerebralhemisphere, with infiltration of the left optic tract A brain biopsy was performed by neurosurgery andpathology was GFAP positive confirming astrocytoma in the brainstem Discussion: About 25% ofastrocytomas are aggressive or high grade Brainstem gliomas make up 10-20% of CNS tumors in children lessthan 15 years old Diffuse midline gliomas are infiltrative tumors, usually with astrocytic morphology and arelocated in the pons, thalamus or spinal cord Most cases have high grade features and are histologicallyconsistent with Grade 4 Treatment includes surgery, radiotherapy and chemotherapy For high grade tumorssurgery can be performed as well as radiotherapy and chemotherapy But without reasonable resectionchemotherapy is palliative Brainstem gliomas cannot be removed, and therefore have a poor outcome Conclusion: Despite lack of in person evaluation, this case highlights the importance of prompt recognitionand action when performing history and physical exams even in this new era of telemedicine In the setting ofthe COVID-19 pandemic, the use of telemedicine proved to be prominent in the diagnosis of this patient

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Respiratory Distress in an Adolescent Girl.

1. Bobby Kumar, MD* 2. Katie Meyer, DO* 3. Leon Rosenberg, DO* 4. Alyson Trillo, DO* 5. Ashley Van Putten, DO, PGY3* 1. *Salah Foundation Children’s Hospital, Fort Lauderdale, FL A 17-year-old girl with past medical history of iron deficiency anemia and depression presented with 6 days of fever (maximum temperature of 103.6°F), cough, congestion, and mild shortness of breath. Other symptoms included nonbloody, nonbilious emesis, decreased appetite, diarrhea, chest pain, body aches, and abdominal pain. When her shortness of breath worsened, she presented to the emergency department for evaluation. On presentation, she was febrile, with oral temperature of 103.1°F, tachycardia, and in severe respiratory distress with subcostal and supraclavicular retractions, decreased breath sounds on the bases, and significant crackles on the right side. Initial oxygen saturation was 89% on room air, with improvement to 98% on 2 L/min of oxygen via nasal cannula. Chest radiograph shows extensive right-sided infiltrates as well as a focal patchy infiltrate on the left (Fig 1). Figure 1. Anteroposterior (a) and lateral (b) chest radiographs showing extensive right-sided infiltrates with patchy infiltrates on the left. Due to right upper quadrant abdominal pain and persistent diarrhea, an abdominal ultrasound was performed, which was unremarkable. Initial laboratory testing on admission revealed no elevated white blood cell count, mild microcytic anemia (hemoglobin 11.3 g/dL, mean corpuscular volume 60.6), hyponatremia (sodium 125 mmol/L), hypokalemia (potassium 3.3 mmol/L), elevated aspartate aminotransferase (141 units/L) and alanine aminotransferase (57 units/L), elevated γ -glutamyl transferase (52 units/L), prolonged coagulation studies (prothrombin time 17.7 seconds and partial thromboplastin time 30.0 seconds), minimally elevated lipase (200 units/L), positive toxicology for cannabis, elevated C-reactive protein of 36.6 mg/dL, negative urine pregnancy test, urinalysis with 100 mg/dL of protein, and a specific gravity of 1.024. Screening for sexually transmitted infections was negative. The …

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