Early Diagnosis of Pediatric Malignancies

(Great Britain—The Practitioner, September 1999, p. 664.) Although childhood cancer is rare, and the early symptoms are often insidious and nonspecific, a high index of suspicion should be maintained, especially when children complain of persistent lethargy or are noted to have progressive pallor. Approximately one child in 600 develops cancer by 16 years of age. Early diagnosis improves clinical outcome and can benefit family coping strategies and relationships with health care professionals. Anemia is frequently the presenting condition for cancers, particularly leukemia and lymphoma. Unusual masses and bone pain should also raise suspicion of malignancy. Cervical nodes smaller than 2 cm in diameter are unlikely to be associated with malignancy in a child who has no other signs or symptoms, but a chest radiograph, an abdominal ultrasound examination and a full blood count may be useful to exclude malignancy in suspicious cases.

Myocarditis

(Great Britain—The Practitioner, August 1999, p. 619.) Most cases of myocarditis are the result of a viral infection (e.g., coxsackievirus, influenza, Epstein-Barr, cytomegalovirus or human immunodeficiency virus), but other organisms or physical insults (including radiation) can cause inflammation of cardiac muscle cells. The pathologic features of myocarditis depend on the cause and the immune response, but cell death and fibrosis may result. The clinical picture may also vary depending on the etiology and extent of the inflammation. In many cases, a prodromal illness precedes symptoms of cardiac involvement—breathlessness, fatigue, chest pain, palpitations and syncope. Sudden death is possible. The diagnosis depends on suspicion and evidence of cardiac malfunction. Management is directed at maintaining cardiac function, treating the cause and minimizing sequelae. Many cases require bed rest and monitoring for arrhythmias and development of cardiac failure. Most patients with myocarditis recover but require follow-up to monitor long-term cardiac function.

Pituitary Tumors

(Australia—Australian Family Physician, May 1999, p. 455.) Pituitary tumors may present as a local mass effect, excessive hormone production or deficiency of pituitary-controlled hormones. Headache is relatively uncommon even with large tumors, but other mass effects, especially on the optic pathways, can occur, depending on the size and location of the tumor. The most common hormonal excess is prolactin, leading to galactorrhea and menstrual disturbances in women and loss of libido in men. Acromegaly and Cushing's syndrome are much less common and may present initially with subtle clinical signs and symptoms. Patients with deficiency of all pituitary hormones show the signs and symptoms of combined loss of growth, sex, thyroid and adrenal function. Hypothyroidism usually presents initially, and adrenal malfunction may be masked until later stages of the disease. In addition to biochemical and endocrine investigations, imaging of the pituitary, usually by magnetic resonance imaging, is essential to define lesions and their relationships. Treatment of pituitary tumors may involve surgery, medication, radiotherapy or a combination or these modalities. The patient may require an individualized management plan involving several subspecialists, the primary care physician and other resources.

Fecal Soiling in Children

(Great Britain—The Practitioner, September 1999, p. 644.) Fecal soiling—the inappropriate involuntary passage of liquid stool caused by chronic constipation and fecal overflow—is fairly common. About 3 percent of five-year-old children have fecal soiling. The condition is more common in boys; approximately 1 percent of boys are still soiling at 10 to 12 years of age. This condition is strongly associated with poor social environment, parenting difficulties and learning disturbances. Ensuing emotional and social problems are common for the child and family. Management includes support of child and family, use of stool softeners and laxatives, attention to diet, and measures to re-establish self-esteem and social functioning. Treatment must be prolonged to remove chronic constipation and avoid recurrence. Enemas may be required initially, followed by a regimen of laxatives or stool softeners such as prune juice. True encopresis is the passage of normal stool at inappropriate times and places, such as into clothing or onto the floor. This condition may indicate severe emotional and behavioral problems. In such cases, intervention by subspecialists in pediatric mental health may be appropriate.