A 9-Year-Old Girl With Declining School Performance

Faisal M. Mawri, MD; Peter Stoyanoff, MD; Meaghan Misiasz, BA; Jillian Ewing, BS; David Ishiyama


May 14, 2015

The prognosis of patients with diffuse intrinsic brainstem gliomas is poor, with a typical survival of less than 12 months after diagnosis. Treatment modalities are limited and have thus far failed to yield significant increases in survival. Given the location and degree of infiltration, most diffuse brainstem gliomas cannot be surgically treated.

The standard treatment currently involves radiation therapy, which may produce temporary neurologic improvement but does not improve overall survival. Although several agents are currently under study, no effective chemotherapeutic agent for the treatment of brainstem glioma has yet been identified.[5,6]

Once the diagnosis was made, the patient in this case was admitted to the pediatric intensive care unit (ICU) for further evaluation and monitoring. No biopsy was performed, because the MRI findings clearly established the diagnosis and biopsy would not have yielded any additional information applicable to her care but would have considerably increased morbidity.

Oral dexamethasone (Ozurdex®) was given to reduce brain edema around the tumor. While in the pediatric ICU, the patient's ataxia, vomiting, and headaches improved, and she was subsequently transferred to the hematology/oncology ward. On the basis of the location of the pontine glioma, the mass was thought to be inoperable; therefore, radiation therapy was initiated on an inpatient basis. Nausea, headache, and abdominal pain were reported after radiation therapy and were treated with acetaminophen, ondansetron, and metoclopramide.

The child's prognosis was thought to be poor, with an estimated life expectancy of 12-15 months. Radiation therapy was continued on an outpatient basis.

Palliative care and social support resources, which are of key importance to patients and families affected by the diagnosis of brainstem glioma, were offered to the child and her parents. The patient lost her hair and had significant weight loss, and she became depressed. She died 6 months after her diagnosis.

The differential diagnosis for a child with poor school performance is extensive; it encompasses psychosocial, neuropsychiatric, and organic disease causes. In children who present with unexplained poor performance in school or changes in personality, a thorough workup that includes a detailed neurologic examination is vastly important. For over a year, the only symptom of the growing intracranial neoplasm in this child was her deteriorating school performance. She went from being an exemplary student to failing classes, even with help from a tutor.


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