A 7 year old boy from Remote village presented with complains of vomiting 4-5 episodes per day for 3 months, inability to walk without support for 20 days and loss of vision in both eyes for 12 days.

According to the parents, the child developed vomiting , without associated Nausea, which was aggravated in the morning after arising from bed. Vomiting was projectile in nature and 2-3 episodes per day, progressively increasing to 4-5 episodes per day. Content of the vomitus was food and water, not bile or blood stained. No history of  abdominal pain, fever, loose stool or intake of any medications, or toxins.

He complains of headache, tight in nature, more prominent in early morning and later localized to nape of the neck and was aggravated on movement of the head ( turning the head ). Then he started having unsteadiness while walking , progressively leading to inability to walk without support. Child had difficulty in changing clothes and used to fall frequently.

Child used to tilt his head and started complaining of loss of vision which progressed to complete blindness since last 10-12 days. Since then child has been bed ridden.

Although the child has bladder and bowel sensation and parents have been helping him, he often passes urine and stool in bed.

There is no history of frequency of micturation neither there is any complain of burning sensation or urgency. No history of abdominal pain or loose stool.

There is complain of change in behavior however.
There is no history of Loss of consciousness , seizure or any localized abnormal body movements. No history of any trauma. Patient has no difficulty in raising his hands above head, or combing his hair.
No history of Cough and cold,or Shortness of breath .
Appetite has been decreasing .

For this problem he had gone to Zonal Hospital where investigations were done – CT scan and Lumbar puncture done. After the reports were suggestive of Brain tumor- Medulloblastoma they referred him to Higher centre for further management 2 months back.
But due to economical problem they presented late , ie after 2 months after the symptoms were severe  and disabiling.

On Examination-
General condition- The child was restless and had a vacant stare. He had twitching movement of upper lips.

Vitals- Blood Pressure – 130/90 mmHg PR-68/min RR-24/min, irregular Temperature- 98 F
P I L Cy C L O D – nil

CNS examination-
GCS- 15/15
Higher mental functions- Intact
Cranial Nerve examination-
CN I- Intact
CN II Optic nerve- No perception of light, papillary reflex present bilaterally both direct and consensual.
CN III,IV and VI- Extraocular movement could not be examined due to complete loss of vision.
CN VIII- Hearing was normal.
Rest of CN were intact.
Motor system examination- Bulk, tone, power – Normal bilaterally, Gait- could not be tested, co-ordination-Normal, Reflexes were Normal.
Sensory system- Normal.
Cerebellar signs- Dysadidokinesia +, Rebound Phenomenon + , others could not be assessed.
Signs of Meningeal Irritation- Neck rigidity +, Kernig sign +, Leg Brudginski –

Chest , CVS and Per Abdomen examination were all Normal.

CT Scan-
CT scan showed- dense white large infratentorial mass in the posterior fossa, in the midline occupying nearly 70% of the posterior fossa , without any calcification or hemorrhage.

Fundus Examination revealed- B/L Papilledema.

Patient was Diagnosed as – Medulloblastoma with Hydrocephalus

Plan- Palliative Ventriculo-pontoneal Shunt.

Dr Sujit Kumar Shrestha

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Last updated: December 31, 2011

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