Case
A 15-year-old boy presented with severe headache and vomiting. Emergency CT head showed a mass in the patient’s fourth ventricle in the posterior fossa, later identified as a Classic Medulloblastoma (WHO grade IV, WNT-activated, CTNNB1 mutated, M1 Chang stage disease) by biopsy. The patient underwent a right frontal EVD insertion, posterior fossa craniotomy and resection and a haematoma evacuation. He was eligible for, and underwent, proton beam therapy to the craniospinal axis with boost to the posterior fossa. Following this, an MRI showed no recurrent or residual disease and he proceeded with post-operative chemotherapy.
Following the CCLG standard risk guidelines, he was treated with lomustine, vincristine, cisplatin and cyclosphosphamide. Details of the chemotherapy are shown in table 1.
In cycle 1, vincristine, lomustine and cisplatin were given on day 1. At day 2, the patient developed severe haematuria with gross clots, causing significant dysuria. The patient declined catheterisation and was managed with intravenous fluids at 150% maintenance and analgesia.
Creatinine increased from 56umol/L pre-chemotherapy to 73umol/L. He had a prolonged prothrombin time (15s) and was given 5mg of vitamin K twice daily. Platelet count was normal.
He subsequently developed significant hesitancy, urgency and dysuria in addition to passing more clots. The patient was passing urine every 15 minutes at its worst, associated with significant pain. A clinical diagnosis of HC was made. He required red-cell transfusion for a haemoglobin of 60g/L and was treated with oxybutynin, SPP and morphine patient-controlled analgesia (PCA) on the advice of urology. A repeat ultrasound at day 9 showed a thickened, hyperaemic bladder wall with echogenic debris, in keeping with HC. Catheterisation was felt not to be in the patient’s best interest as despite pain he was passing urine regularly.
Urine culture was negative with no presence of pyuria or organisms on microscopy. Urine dips were positive for blood and white cells, but no nitrites. Urine (x2) and plasma samples for BKV were negative. Cytomegalovirus (CMV), Epstein-Barr virus (EBV) and adenovirus serology were negative. Throughout this episode, the patient’s neutrophils remained within normal range. C-reactive protein was 32mg/L at its peak.
The patient recovered by day 14. Frank haematuria stopped at day 10. Oxybutynin, PCA and SPP were weaned and further vincristine was delayed to day 21. The patient did not experience a recurrence of HC.