A 4-year-old male Hindu patient presented with fever for 2 days, cough for 5 days, abdominal pain for 4 days, and weakness in the lower limbs for 2 days. On examination, he had pallor and decreased power and reflexes in the lower limbs. Investigations revealed anemia and abnormalities on chest x-ray and MRI of the spine. He was started on steroids and showed improvement. Further imaging found a mass near the kidney and involvement of the bone marrow and spine. Biopsy results supported a diagnosis of neuroblastoma.

1. Dr. NILESH PANCHAL M.D.(PED) ASST.PROFESSOR ,B.J.MC. 9898554437 [email_address] 8/4/2010

2. A 4 Yr. Old, Male, Hindu Pt. , Residing At Gandhidham, Admitted With Complaints Of Fever For 2 Days Cough For 5 Days Pain In Abdomen For 4 Days Weakness Of Lower Limbs For 2 Days 8/4/2010

3. Fever-----low Grade, Intermittent, Without Chills And Rigors,relieved By Oral Medications. Cough-dry, no paroxysm, no breathlessness Abdominal Pain----dull, intermittent ,Not Radiating, relieved By Itself Weakness Of Both Lower Limbs---not Able To Walk 8/4/2010

4. No H/o trauma I. M. Injection ,recent vaccination bleeding from any site Vomiting ,frequency of stool Ear discharge Convulsion or altered sensorium dog bite 8/4/2010

5. No H/O Similar Episodes In Past. Family History –Not Significant Birth History– Uneventful Immunization History—complete For Age Development H/O –Normal For Age no Regression Of Developmental Milestones 8/4/2010

6. Treatment Taken Before Hospitalization Tab. Prednisolone For 2 Days Investigations Are Hb—6.4 TC—3300 DC 30/68/1/1 Platelets-1,70,000 PS For MP- Not Seen 8/4/2010

7. Conscious, oriented To Time ,Place ,Person, follows Verbal Commands Weight 15 Kg Temp. Normal H.R.-102/Min B.P.-106/58 mm of Hg Pallor No Lymphadenopathy No Icterus No Clubbing 8/4/2010

8. R.S.-Right Few Lower Zone Crepitations CVS-NAD P/A; No Organomegaly., No Lump Or Mass Palpable 8/4/2010

9. CNS: Conscious No Cranial Nerve Palcy No Signs Of Raised I.C.T. Pupils Round And Reacting To Light Tone Decreased In Both Lower Limbs Power—5 In Both Upper Limbs And 0 In Both Lower limbs 8/4/2010

10. Abdominal Reflex –Absent Knee Reflex----absent Planter– Absent Scrotal—absent Anal—absent Spine Normal No Neck Rigidity 8/4/2010

11. Hb-8 Gm TC—7000 DC—55/40/4/1 Platelets-5,20,000 Microcytic,hypochromic Anaemia PS For MP Not Seen Bld.Urea—17 S.Creatinine-0.6 S.Na+--138 S.K+--4.6 8/4/2010

12. 8/4/2010 X-ray Chest Suggestive Of Rt. Lower Zone Consolidation X-ray Of Dorso Lumbar Spine Is Normal S.Widal Negative Aso- Positive

13. Pt. Had lost bowel bladder control No Fever Cough Perssisted Considering GBS Inj.METHYL PREDNISOLONE Started On 2 nd Day Of Admission. 8/4/2010

14. Inj. Methyl Prednisolone For 1 Day Next Day Pt. Improved Markedly In The Form Of Lower Limb power Is 4/5. On 3 th Day Of Admission Pt. Had acute Abdominal Pain Subsided By Analgesics. And Ranitidine Adviced For USG Abdomen 8/4/2010

15. 8/4/2010

16. 6*8 Cm Sized,heterogenous Echotexture Lesion With Internal Calcification Mass Anterior And Superior To Kidney,which Engulf Major Vessels Multiple Enlarged Para Aortic And Retrocaval Abdominal Lymphnodes. 8/4/2010

17. Altered Signal Intensity Soft Tissue Lesion Left Para-spinal Region Extending In Post.Epidural Space From D1 To D9 And D12 To L4 Vertebra levels .Complete Epidural Block At That Level 8/4/2010

18. SMALL ROUND CELL TUMOUR- NOT LYMPHOMA NEUROBLASTOMA WILM’S TUMOUR 8/4/2010

19. BONE MARROW INVOLVED BY MALIGNANT ROUND CELL TUMOUR NSE-POSITIVE CD99-POSITIVE NF-POSITIVE DIAGNOSIS ? 8/4/2010

20. NEUROBLASTOMA 8/4/2010

21. 8/4/2010