Case Reports in Pediatrics / 2015 / Article / Tab 1

Case Report

A Case Study of Intractable Vomiting with Final Diagnosis of Neuromyelitis Optica

Table 1

Timeline of presentation and diagnosis.

DateChief complaint/historyConsultantDiagnostic studyFindings and treatment

Urgent care visit
(i) Vomiting 
(ii) Unintentional weight loss
Primary carePrescribing ondansetron and follow-up with PCP for weight loss

PCP follow-up office visit
(i) Gastritis 
(ii) Weight loss 
(iii) Orthostatic hypotension 
(iv) Intermittent right lower back pain with radiation into the right leg
Primary care(i) Beck’s Anxiety and Depression Inventory 
(ii) CBC, CMP 
(iii) Lipid Panel 
(iv) TSH
(i) Mild anxiety 
(ii) No depression 
(iii) All labs normal 
(iv) Normal reflexes, muscle tone, coordination

ER visit
(i) Vomiting 
(ii) Dehydration 
(iii) Weight loss
(i) Chest X-ray  
(ii) CBC, CMP  
(iii) Urine pregnancy test and UA 
(iv) ESR 
(v) CRP
(i) All normal, except low prealbumin at 18 and sodium 136 
(ii) Given IV fluids 
(iii) Discharged on promethazine for vomiting and nausea

Community hospital admittance with same day transfer to children’s hospital
(i) Intractable vomiting 
(ii) Weight loss 
(iii) Hypertension 
(iv) 5-day history of hiccoughs
Pediatric GIRight upper quadrant ultrasoundSmall amount of gall bladder sludge, no gallstones
CT abdomen pelvis with contrastNormal
EGD (i) H. Pylori gastritis, biopsy diagnosis 
(ii) Triple therapy was initiated, changed to IV due to persistent nausea and vomiting, completed
Colonoscopy with biopsies No abnormalities
Pediatric nephrology Urine VMA, Renal ultrasoundBoth normal 
Pediatric nutrition  (i) 15% weight loss in 3 months 
(ii) 27th percentile weight for age 
(iii) 32nd percentile stature for age
NeurologyNormal strength, tone, movement
Discharge Diagnosis: 
H. pylori gastritis 
Triple therapy for H. pylori: clonidine patch, pantoprazole, sucralfate

ER visit/transfer to children’s hospital
(i) Pancreatitis 
(ii) Hypertension 
History: 2 fleeting episodes of blurry vision, lightheadedness, pain, itching on left side of face since 9/24, syncope on 9/25 with 10-second loss of consciousness, difficulty following commands
Pediatric neurology(i) Brain CT 
(ii) Brain MRI
(i) Both Normal 
(ii) Normal strength, tone, movement 
(iii) PT consult for instability in ambulation
Pediatric GIEGD with biopsy for emesis(i) Gastric nodularity, H. pylori positive 
(ii) Lipase 465–1498, Lactic acid 2.7 elevated
Pediatric nephrologyEchoNormal
Discharge diagnosis: 
Dehydration, abdominal pain, intractable vomiting, syncope, H. pylori infection, neuropathic left facial pain (worsened on gabapentin, so stopped) 
Clonidine patch 0.1 mg/24 hr weekly, pantoprazole 40 mg 2x daily, sucralfate 1 g 2x daily prn, ondansetron 8 mg 2x daily prn

PCP follow-up from hospitalization
(i) Pancreatitis 
(ii) Hypertension 
History: lower extremity weakness, numbness in fingers, hyperesthesia of the face and head, shaking episodes, feeling cold, mom reports symptoms worsening, had “seizure” in hospital
(i) Lipase 
(ii) West Nile IGG and IGM 
(iii) ESR 
(iv) TSH
(i) Physical exam: normal reflexes, no cranial nerve deficits, normal muscle tone, decreased sensation in extremities 
(ii) Labs normal except elevated lipase (277) 
(iii) Cold intolerance 
(iv) Spells 
(v) Urgent referral to neurology

Office visit with pediatric neurology resulting in hospitalization at children’s hospital
History: shaking episodes since 9/27 affecting head and upper extremities, occur randomly, last seconds with no postictal confusion, pins and needles sensation affecting entire face and left arm, itching and burning of left face with hyperpigmentation, weakness requiring wheelchairPediatric neurology, pediatric GI, adolescent medicine, neurosurgeryNeurological exam(i) Cranial nerves intact 
(ii) Sensation intact 
(iii) Bilateral upper and lower extremities 
(iv) Right upper extremity strength 5/5  
(v) Left upper extremity strength 4/5  
(vi) Pronator drift 
(vii) Bilateral lower extremities 4/5 
(viii) Gait weak on left side
Continuous 24-hr. Video EEGNormal in awake, drowsy, sleeping states; 7 episodes with no EEG correlate
EMG and Nerve conduction studyNormal 
(i) Ceruloplasmin 
(ii) Vitamin D 
(iii) Cortisol 
(iv) Lipase 
(v) ANA profile 
(vi) Entrovirus
(i) Low 
(ii) Low  
(iii) Normal 
(iv) Elevated lipase (771) 
(v) Negative 
(vi) Negative
Discharge Diagnosis: 
(i) Left-sided upper and lower extremity weakness 
(ii) Spells 
Vitamin D deficiency, hydrocortisone cream, ondansetron, sucralfate, vitamin D, multivitamin, ranitidine

PCP f/u hospitalization
(i) Pain in bilateral upper extremities, chest, low back 
(ii) Shaking
Lipase(i) Almost normal (126) 
(ii) Myalgias 
(iii) Parasthesias 
(iv) Spells 
(v) Tremors 
(vi) Hypertension 
(vii) Urgent referral to pediatric neurology

Pediatric neurology
(i) Pain in bilateral upper extremities, chest, low back 
(ii) Shaking
Pediatric neurology(i) MRI whole spine, with and without contrast (performed on 11/3) 
(ii) Neurological exam
(i) Tremors 
(ii) Parasthesias (face, arms, trunk, legs) 
(iii) Nonspecific muscle tenderness, possible weakness 
(iv) Reflexes normal, downgoing plantar Muscle normal bulk, tone, strength 
(v) Decreased cold face to T4, decreased pinprick face to toes.
(vi) Recent history of pancreatitis

pediatric GI f/u hospitalization
Intractable vomitingPediatric GISerum copperNormal

PCP follow-up
MRI results(i) MRI cervical spine 
(ii) MRI thoracic spine, lumbar spine, sacrum, coccyx
(i) 4 × 3 cystic dilation of the central canal from C5 to T2 
(ii) Increased signal in the medulla oblongata and C2 to C5, relative expansion of the cervical spinal cord 
(iii) Syringomyelia  
(iv) Normal

pediatric neurosurgery
Abnormal cervical spine MRI 
History: decreased activity due to neck pain, difficulty starting urination, hand tremor, weakness in all extremities, numbness and tingling in left leg
Pediatric neurosurgeryNeurological exam(i) Abnormal reflexes, increased muscle tone, clonus in both feet, spastic gait 
(ii) No muscle atrophy, no cranial nerve or sensory deficit, normal position and vibration sense, normal coordination 
(iii) Possible multilevel spinal cord tumor 
(iv) Referred to 2nd children’s hospital neurosurgery

ER visit and hospitalization at a second children’s hospital
Possible multilevel spinal cord tumorChild neurology(i) Lumbar puncture 
(ii) MRI cerv. spine
(i) CSF positive for neuromyelitis optica (NMO), WBC 18, RBC 3, gram stain culture negative, IgG index 0.6, oligoclonal bands negative, ACE 1.1, NMDA receptor antibody negative; seropositive for NMO.
(ii) Extensive cervical spine longitudinal myelitis; confluent ill-defined, partly enhancing, abnormal intramedullary signal from pontomedullary junction through the lower cervical cord. No optic nerve abnormality.
(iii) Dystonia 
(iv) Tegretol 300 mg 3x daily 
(v) 2 days of IV IG 
(vi) 5-day course of IV methylprednisone, discharged on prednisone taper
Discharge diagnosis: 
(i) Neuromyelitis optica (NMO) 
(ii) Cervical myelopathy 
(iii) Dystonia

Follow-up with pediatric neurology
(i) Neuromyelitis optica (NMO) 
(ii) Cervical myelopathy 
(iii) Secondary Paroxysmal Kinesigenic Dyskinesia (PKD) 
(iv) Start Cellcept with slow increase to goal of 1000 mg BID

Follow-up with PCP
(i) Neuromyelitis optica  
(ii) Cervical myelopathy
(i) Weight gain since November of 34 lb 
(ii) Taking mycophenolate, carbamazepine, prednisone 
(iii) Referral to ophthalmology for baseline evaluation and ongoing care