A case of recurrent emesis in a pediatric patient

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A previously healthy 15-month-old male presented to the pediatric emergency department with complaints of intermittent vomiting for the past 2 months. He was seen in a primary health care center 2 months prior for vomiting and was diagnosed with gastritis. He received an intramuscular (IM) anti-emetic injection on his right buttock and was sent home. His vomiting persisted, and his mother noticed that the child was refusing to walk. His parents sought medical advice in an emergency department and the physician related the abnormal gait to the IM injection and suggested to observe him at home until his symptoms improved. However, when the parents noticed that even after a few days the patient was still refusing to walk, they brought him to our emergency department. On physical examination, he appeared well hydrated and well nourished with normal vital signs for his age. Neurological examination revealed normal tone and power in all muscle groups. However, bilateral lower extremity deep tendon reflexes were brisk with bilateral ankle clonus. When encouraged to walk, we observed that he was ataxic, but did not exhibit pain. Head circumference was found to be 51 cm (>2 SD for age and sex). The remainder of his physical examination was unremarkable. Given that he had the history of an IM medication before his refusal to walk, our differential diagnosis included painful ataxia secondary to medication administration via IM route versus an intracranial pathology. Given that it is rare for an IM injection to cause prolong period of ataxia, providing him with a non-steroidal anti-inflammatory drug would have helped differentiate if his ataxia was secondary to the IM injection. However, during his physical examination he did not exhibit pain when he tried to ambulate, plus this would have not explained the episodes of recurrent emesis. Suspecting an intracranial pathology to his vomiting and abnormal gait, the patient was admitted to the pediatric floor with scheduled magnetic resonance imaging the next morning. Magnetic resonance imaging showed a well-defined rounded midline space-occupying lesion seen in the posterior fossa measuring 4.4 × 4.5 × 5.1 cm. The lesion showed heterogenous signal intensity in T2-weighted fluid attenuated inversion recovery with area of fluid signal intensity in T2 suggestive of necrotic/cystic changes (see Figures 1 and 2). There was heterogenous contrast enhancement after gadolinium. The mass extended through the foramen of Magendie, but not through foramen of Luschka, causing mass effect on the brainstem with expansion of the fourth ventricle causing obstruction of the third and lateral ventricles, that is, extensive obstructive hydrocephalus. In a gradient echo sequence/susceptibility weighted angiography sequence, there are multiple tiny intra-lesion signal voids suggestive of calcifications. Magnetic resonance spectroscopy revealed elevated choline with decreased N-acetyl aspartate. No appreciable meningeal and leptomeningeal enhancement could be detected. Cranio-cervical junction and cervical cord were normal. The most common reason for pediatric emesis outside the neonatal period is acute gastroenteritis with nearly 1.5 million annual outpatient visits in the United States alone.2 Although the most common cause of emesis is related to the gastrointestinal tract, vomiting is also the initial sign of an intracranial pathology in approximately 24% of patients.3 Other than recurrent vomiting, the regression of previously achieved milestones as well as the presence of upper motor neuron signs and ataxia were additional important red flags in our case. Brain tumors are the most common solid tumors and the second most common overall pediatric malignancy.3 Ependymomas comprise 8% to 10% of the childhood central nervous system tumors, making it the third most common central nervous system malignancy.4 Ependymomas originate from the neuroepithelial cells of the ependymal lining of the ventricular system. Of ependymomas, 90% are situated intracranially with two thirds located infratentorially in the posterior fossa.5 This location is most common in children younger than 3 years of age.6 The remaining arise from the supratentorial region and the spinal cord.5

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