Ependymoma as a final diagnosis of pneumonia suspect: case report

Case presentation: A 1 year and 5-month-old female patient presented with 14 days of continuous fever. Initial consultation led to amoxicillin treatment followed by ceftriaxone and cefuroxime for bacterial pneumonia, remaining afebrile since then. Vomiting ~2 times a day, however, remained. Three days after this, there was a worsening of vomiting, now occurring 8 times a day, without other gastrointestinal symptoms, which led her parents to the hospital. The history told motivated to hospitalize the patient for a more careful evaluation. New laboratory showed microcytic anemia, leukocytosis with a predominance of segmented (59%), moderate hypokalemia, elevated alkaline phosphatase, LDH and ESR. Chest X-ray taken on admission showed mild bilateral infiltrate. On the same day of admission, the patient had sensorineural lowering (ECG 13/15), onset of horizontal nystagmus without signs of neck stiffness. The following day, there was an increase in nystagmus, with an epidose of opistotonia lasting until diazepam administration. CT and MRI of the skull revealed a bleeding tumoral lesion in the posterior fossa and hydrocephalus. The patient followed for cranioplasty for tumor biopsy and installation of cerebrospinal fluid fistula. Anatomopathological lesion attested grade 2 ependymoma. The patient evolved well in the postoperative period, however, developed aphasia, deviation of the mouth's gaze to the right, and hemiparesis to the left.

Discussion: Ependymomas are tumors derived from ependymal cells lining the brain ventricular surface. This tumor has a peak in childhood with a higher incidence in males. The median age of diagnosis is 5 years, and ~25% are diagnosed under 2 years old. Ependymoma can occur anywhere in the ventricular system or spinal canal, but the most common site is the fourth ventricle. Histologically, they are classified into grades 2 and 3, with grade 2 being classic and grade 3 anaplastic. Symptoms are based on increased intracranial pressure due to hydrocephalus, which results in headache, nausea, vomiting, ataxia, vertigo, and hemiparesis may occur. The therapy consists of resection of the tumor mass.

Final comments: The present work emphasizes the importance of valuing the patient's complaints, considering that the patient was treated repeatedly with antibiotics for the vomiting and fever without a proper etiological investigation for the warning signs. Rapid diagnosis and adequate treatment could prevent sequelae development.

Publication History

Article published online:
18 September 2023