Dr.Ch Venkat Kumar raju, Dr.C. Jayakumar
One year old asymptomatic child presented with fever one week and irritability poor oral intake of three days and B/L lower limb swelling. Symptoms suggestive of cardiac renal and hepato biliary systems were absent . Referral was for High counts and abnormal sonogram
Differentials considered were
Renal, hepatic problems, Malnutrition ,lymphedema and cardiac condition
Vitals we’re stable at presentation except fever of 101 degrees F
PICCLE negative
• Hepatomegaly with Span of cm
• Bilateral pitting pedal edema
• ECHO- Has extensive thrombus in RA and IVC
| TC | 27K |
| N/L | 38/54 |
| HB | 10.8 |
| PLT | 4.3L |
| CRP | 25 |
| Urea | 46 |
| Creat | 0.45 |
| TSB | 1.01 |
| DSB | 0.56 |
| Protein | 5.7 |
| Alb | 3.7 |
| Glob | 2.06 |
| SGOT | 2612 |
| SGPT | 2060 |
| INR | 2.19 |
| NT bnp | 2481(0-18pg/ml) |
| CPK | 1539(10-120mcg/l) |
| LDH | 1903(120-200U/l) |
| Ferritin | 818(7-140ng/l) |
| DCT | – ve |
| D-dimer | 2.47mg (0.04-2.2mg/L) |
| Fibrgen | 235(200-400) |
Peripheral Smear- Normocytic normochromic anemia with normoblastemia and polychromasia with leucocytosis
• Lupus anticoagulant panel- negative
• Thromboelastography- normal
At this point differentials consisted were
•Procoagulant states-
1. Inherited- Protein C , Protein S , Antithrombin 3 deficiency, factor V leiden deficiency
2. Malignancy(hepatic>abdominal>pelvi
•Heparin infusion was started and
CECT Abdomen was taken
• A large highly vascular soft tissue mass seen in coccygeal regions measuring (3.5 x 3.6 x 4.4cm) intraspinal extension of this lesion uptill L3/L4 level
• Extensive thrombus involving Bilateral external iliac, internal iliac, common iliac extending into IVC and right atrium, proximal renal veins were thrombosed.
• Appearance suggestive of an Aggressive Neoplastic Lesion ? Sarcoma
Tumour thrombus in RA
| AFP | 94653 (6-590ng/ml) |
| B-HCG | <<1 |
| CEA | 3.34 (0-2.9ng/ml) |
| CA 125 | 322 (0-35U/l) |
HPE showed- Impression:
• Retro Rectal mass – Malignant Mixed germ cell tumour (Endodermal Sinus tumour and Dysgerminoma)
Take home message
When we come across generalised edema especially when it is non pitting imaging and other speciality involvement is of paramount importance