CASE:
A 6 year old girl presented to the hospital with the main complaint of
dyspnea and pleuritic chest pain starting from one week earlier. She was
mildly agitated and could not lay down due to pain and ortopnea; She was
also febrile during this period. In her past medical history: she is the
first sibling, was born term, with no previous hospitalization. Her
parents reported intermittent fever for 3 months before admission. There
was no close contact with a suspicious covid-19 patient.
Upon physical examination, general appearance was good and the child was
mentally oriented. Lung auscultation was clear but a region of decreased
sounds was detected on the lower right side, heart sounds were muffled,
and the peripheral pulses were normal at the time. The blood pressure
reading was 100/65, heart rate was 120, and respiratory rate was 30.
Abdominal examination revealed hepatomegaly.
Initial paraclinical studies included chest radiograph which showed a
mediastinal widening (figure 1) and 12-lead electrocardiogram revealed
sinus tachycardia and low-voltage alternans QRS (figure 2). Complete
blood test, blood biochemistry assessment and COVID-19 PCR test were all
normal (table 1).
Further evaluations were performed based on the primary findings, which
included echocardiography showing significant pericardial effusion, and
thorax computed tomography (CT) scan revealing a mediastinal mass
accompanied by pleural and pericardial effusion (figure 3 and 4).
The biopsy from the mass was in favor of non hodgkin lymphoma (malignant
small round cell tumor), bone marrow aspiration was normal and bone
marrow biopsy demonstrated cellular hematopoietic, non-neoplastic marrow
(figure 5). Chemotherapy was initiated after referral to oncologist,
immunohistochemistry tests, and complete staging. The chemotherapt
regimen was consisted from Prednisone (oral administration), vincristine
(intravenous administration on), daunorubicin (intravenous
administration), asparaginase (intravenous administration),
cyclophosphamide (intravenous administration), cytarabine (intravenous
administration), mercaptopurine (oral adminestration), and mitothrexat
(intrathecal administration). After one yeard of follwo up, the patient
is disease free.