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1. Klinik Desa Sg Buaya
Under Five Mortality
Nisithaa A/P Ramesh

2. Patient’s Details
• Name: Nisithaa A/P Ramesh
• DOB: 19/08/2018 @ 2102H (BW2.32kg) 37/52+3/7
• (2nd twin)
• 1st twin BW:2.29kg
• SVD delivery
• POB: Hospital Sg Buloh
• DOD: 8/1/2022 @2015 at 3years 4months old
• COD: Choroid Plexus carcinoma
• Place of death : Hospital Kuala Kubu Bharu

3. Mother’s Details
• Name: Manimegalay A/P Muniandy
• Age : 44 years old
• Address : No 12,Jln Kembojasari 13,Bandar Sg
Buaya.
• Highest Education :Form 3
• Occupation : Housewife

4. Father’s Details
• Name: Ramesh A/L Subramaniam
• Age : 38 years old
• Address : No 12,Jln Kembojasari 13,Bandar Sg
Buaya.
• Occupation : lorry driver

5. Antenatal summary
• G3P1+1
• Booking done at KD Sg. Buaya @9weeks POA.
ANC issues:
1)Advanced maternal age(40yo)
2)MCDA twins-no evidence on TTS
3) Resolved Anemia in Pregnancy @20weeks
-Hb throughout pre delivery Hb:11.8
-on T.Iberet 1/1 OD
4)Hx of miscarriage in 2013
5) LCB 2014-svd
6)MGTTX2:normal
7)VDRL/HIV/Rapid test: Non-Reactive
8)Blood group: O positive

6. Family history:
• No consanguity in family
• No hx of CA in family
• Elder brother is 9 years old,healthy
Developmental history:
• Gross motor: able to goes upstairs and downstairs,walking,running,rides
tricycle,kicks ball and throw ball.
• Fine motor: able to copies and imitates drawing
• Speech:gives full name,gender,age,able to ask questions,able to name
colors.
• Social:eats independently,able to play with other children,able sharing
toys with others.
Immunisation history: up to age

7. History of Presenting Illness
• Patient came to KD Sg Buaya for all immunization tca up to 1yo.
• Child first presented to Hosp Selayang on 30/9/19(14months old) for
recurrent vomiting and lethargy for 1 weeks.
CT-Brain : large heterogenous mass in the left parietal region(6.2x7.2x5.7cm)
with intralesional bleed,midline shift and hydrocephalus.
• Child then transferred to HKL Neurosurgical proceeded with:
CT-Brain,CTA,CTV:two enhancing lesions in the left parieto-occipital
region(1.1x2.3x2,3.3x3.7x5.5cm) with a large intraparenchymal
haematoma(7.2x6x5.6)
• Left temporo-parieto-occipital craniotomy&tumor excision done on
4/10/19.
HPE findings:Choroid plexus carcinoma
Post-op CT-Brain(5/10/19):showed suspicious residual tumor.
MRI Brain&Spine(7/11/19):no spinal mets,residual tumor within occipital horn
on left lateral ventricle with multiple surgical bed nodule,subependymal left
lateral ventricular,left parasagittal and left frontal convexity nodule suggestive
CSF mets.
• Her post-op period was complicated by subdural hygroma then required Burr
hole & Subdural incision on 11/10/19.

8. • Child was treated with 6 courses of chemotherapy :
CPT SIO 2000(Vincristine,carboplatin,Etoposide)
between (1/11/19-23/3/20).
• After 2courses of chemotherapy:
MRI Brain&Spine(30/12/19) :smaller lobulated residual tumor at occipital
horn of left ventricle(1.2x1.6x1.9) with no significant changes in surgical
bed nodules.Intraventricular nodules reduced in number&size,nodule in left
frontal convexity no longer seen but left parasagittal nodule still present.
• Just before completion of her chemo,
MRI Brain(19/3/20):slightly smaller lobulated residual tumor at occipital
horn of left lateral ventricle with smaller nodules in resection cavity.2
subependymal nodules in left lateral ventricle and left posterior
parasagittal region appeared unchanged.
• Neurosurgeons decided against surgical intervention in
view of intact neurology.

9. • Unfortunately,child presented with status
epilepticus to Hosp Selayang on 11/4/21 and her
anti-epileptics were optimized.
CT-Brain:hyperdense lesion at trigone&posterior horn left ventricle.
• No neurological deficits post seizures.
• On 21/4/21:child presented to HKL with persistent
vomiting:
MRI Brain:significantly larger residual tumor in left parieto-occipital
region with thick peripheral nodular rim compressing left thalamus.
• Proceed with Left parieto-occipital
recraniotomy&tumor excision on 24/5/21.
CT-Brain post-op:small cystic lesion(1.5x1.2) at surgical site
suggestive residual tumor.
• No neurological deficits post-op.

10. • Child underwent radical radiotherapy for
1month(7/7/21-26/8/21).
• However,on 30/9/21,child presented with episodes
of fitting went to Hosp Selayang,this is 4th episodes
since 2019.
MRI Brain:small enhancing lesion in body of left lateral ventricle represent
tumor recurrence.
• Child continue her tca HKL as planned and anti-
epileptics were optimized.
• On 31/12/21:child was referred to palliative team,
discussed with family regarding the
prognosis,parent decided not for
CPR/Intubation/ICU/HDU admission.

11. • On 6/1/22-7/1/22,nurses from Kasih Hospice
foundation went for home visit,noted child sleep most
of the time,but still respond to pain.
• 8/1/22:child had temperature spike in the
morning,mother claimed gave Supp pcm in the
morning and regular Syr pcm,but subsequently,in the
evening around 6pm,mother claimed child unsconsious
and mother called for an ambulance.
• Around 7pm,medical team from HKKB arrived and child
was brought to HKKB.
• Death pronounce at 815pm.
• Cause of death:Choroid Plexus Carcinoma

12. Substandard Care
• Hospital Level
• Nil
• KK Level
• Nil
• Patient & community
• Nil

13. Future Improvements
• For details scan for next pregnancy
• For early booking next pregnancy

14. COD Choroid Plexus Carcinoma
Preventability Not Preventable

15. THANK YOU