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.
