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.