My 15-Year Old Patient Living With A Time Bomb Tumor Had No Clue
By: Eden Kunter
Tags: Case Study, Medical Case, Medical Doctor, Pediatric Cancer, Case Report

My 15-Year Old Patient Living With A Time Bomb Tumor Had No Clue

Photo by Paweł Czerwiński on Unsplash

A 15-year old male sought to the emergency room with chronic nausea and vomiting. He came to my room with only a medical interrupt demand for sickness as he was about to join a family trip.

“There is no diagnose for my case. Sometimes I feel nausea before, but sometimes it is sudden; I throw up until I feel better or take an anti-emetic to suppress it.”

History Taking

I work at the children’s emergency room as a physician. I see at least 100 patients daily, which means I have to be as quick as possible with maximum cautiousness. It is said that over 80% of diagnoses are made on history alone, a further 5–10% on examination, and the remainder on the investigation. He did not volunteer to give me a detailed history, nor his family, as they did it over and over again before.

How do you vomit? I asked. I beg your pardon? He hesitated since he didn’t have to describe his vomiting before.

I asked my questions with a calm attitude and was determined to take my answers:

Is it very sudden?

Does the vomit exit your body with some force?

Does it travel a few feet from you?

What is the color?

As long as you observe, is it related to your diet or not?

Do you have any other symptoms?

I was trying to ask if it is projectile vomiting.

What is projectile vomiting?

Projectile vomiting causes vomit to be forcefully sent out of the patient’s body. It differs from regular vomiting in several ways:

It happens with or mostly without warning of the feeling of nausea.

It is more severe.

It is forceful.

Projectile vomiting has several potential causes such as pyloric stenosis, reflux, stomach obstructions, infections, food poisoning, neurological diseases. Healthcare professionals should make the differential diagnosis based on the patient’s history, additional symptoms, physical examination, and if it is necessary with further diagnostic imaginations.

Physical Examination

I quickly check every physiological finding in other system’s examinations.

On physical examination, he was

Awake and alert, oriented to person, place, and time.

5 / 5 strength with no sensory deficit in all extremities.

Recent and remote memory intact. Good insight and cognitive function. No aphasia, dysarthria, or hoarseness.

Gait and station normal, Rhomberg negative.

Skin warm, dry, good turgor, No abnormal pigmentation, bleeding, rash, or other lesions. Hair normal texture and distribution. No nail changes.

No abnormal tympany. Normal bowel sounds, no bruits. Superficial & deep palpation without organomegaly or masses; no direct or rebound tenderness, rigidity.

“I told you, there is no diagnose for my case. Give me some medications so we can hit the road!” he shouted at me.

At that moment, I realized something. He has anisocoria, which means his pupils were not EVEN! Usually, the pupil’s size is the same in each eye, with both eyes dilating or constricting together.

The term anisocoria refers to pupils that are of different sizes at the same time. Anisocoria can be physiologic, or it can be a sign of an underlying medical condition.

I looked again in these young, angry, dark brown, and anisocoric eyes and asked his parents whether they know about it.

Furthermore, the dilated pupil was unresponsive to light that might be linked with a lesion on neural pathways. To make it more transparent, let’s take a quick, simple look at the pupillary light reflex:

The pupillary light reflex can be tested with a shinning light directly pointing into the eye. The afferent limb of the reflex is on the optic nerve, which initiates sensory input. Shining a light on one eye should show a constriction of the pupils on both eyes. The pupils’ failure to constrict may indicate either an optic nerve lesion, a lesion of the efferent limb (oculomotor nerve), or any other lesion along the path.

Meeting With A Time Bomb: Thalamic Glioma

Was it physiologic? Was it related to the symptoms? I performed an MRI before the patient was admitted to another hospital via an ambulance for further diagnosis and treatment.

And there was it! Shining like a time bomb in his brain!

The time bomb is a glioma that originates from the supporting cells of the brain we call “glial cells.” Since glial cells are present throughout the central nervous system, gliomas can occur in various brain areas or along the spinal cord. A thalamic glioma is a tumor characterized by a primary growth center near the thalamus which plays a significant role in movement, consciousness, and awareness.

Thalamic gliomas usually develop the symptoms when the tumor begins to compress the adjoining ventricle, resulting in a blockage of cerebrospinal fluid flow. This causes headache and vomiting, is referred to as hydrocephalus, and needs emergency attention.

After many procedures and treatments, my patient is finally diagnosed and has been continuing his treatment since then.

Photo by National Cancer Institute on Unsplash

I have dedicated this article to many other lives we will save and all the heroes working every day until every child is well.