CLINICAL BRIEFS
Indian J Pcdiatr 1992; 59 : 5 4 1 - 5 4 7 i
G a s t r i c T e r a t o m a - Review of L i t e r a t u r e A.N. Gangnpadhyay, S.K. Pandit, A. Sinlm, S.C. Gopal and S. Khanna*
Departments of Pediatric Surgery, and *Pathology, hastitute of Medical Sciences, Banaras Hindu University, Varanasi Gastric tcratoma is an extremely rare tumour of infancy and childhood? It is almost exclusively found in malcs and rarcly found in females, t5 The tumours are always benign. CASE REPORT Case 1 A male child of 3 months was admitted in children's Hospital at B.H.U., Varanasi on Fcbruary 1981 with progressive abdominal distension and history of failure to thrive since birth. Child was anaemic and underwcight with a palpable firm mass in left uppcr half of abdomen with a restricted mobility. Plain X-ray film of abdomen showed soft tissue mass with patchy calcification. Intravenous urography showed downward and mcdial displacemcnt of left pelvicalyceal system. Barium study of uppcr GIT showed anterior and upward displacement of Ihc stomach. On exploration, the tumour was arising from the postcrior surface and greater curvature of fundus and body of stomach and was exogastric. Turnour was excised akmg with a portion of greater curvature of stomach. The tumour was weighing 1120 gms (Figure 1). Histology showed a benign picture of tcratoma. Case 2 A male infant of 7 days was admitted on November 19")0 to our hospital with complaints of abdc~minal distension and he-
Fig. l.Cut surface of the excised specimen of gastric teratoma in case no. 1 weighing 1120 g. matcmesis and malcna. The child was anaemic and had a marked abdominal distension with a mass palpable in the upper half of abdomcn, with a variable consistency. Plain X-ray film of abdomen showed soft tissue mass in upper abdomen with few areas of calcification. Ultrasonography showed an extra rcnal mass which was partly echofree and partly echogenic but exact anatomical location was not clear. Intravenous Pyelogram (I.V.P.) showed bilateral hydroncphrosis and displacement of kidneys and ureters. Exploratory laparotomy showed a tumour arising from the anterior surface of the body and fundus of the stomach. Tumour had a small endogastric component as well (Figure 2). Tumour weighed 500 gms and the histopathology showed teratoma with prcmalignant changes. Child is how-
5,12
Tl IE INDIAN J t ) U R N A I , ()F P E D I A T R I C S
Vol. 59, No. 4
of a lump) m6 Patients may however also prcsent with gastrointestinal bleeding occasionallyl'7'~~ as encountered in our second case. Plain X-ray film of abdomcn shows either calcification or presence of a calcified mass in more than 50% of c a s e s , lt'19 Sometimes teeth or bone may be s e e n . 2~
Fig. 2.Excised gastric teratoma weighing 500 g of case no. 2 showing mainly cxo-gastric with a small endogastric component below, ('[' indqcating the linc of demarcation). cvcr progrcssing well and has gained weight. DISCUSSION Gastric teratoma was described for the first time by Eusterman & Sentry in 1922 in a 31 year old male paticnt. 6 Since then 65 cases have been reported in the litcrature. Gastric tcratoma constitutes less than 1% of infant teratomas and about 1.6% of abdominal leratomas. 7`s It is found exclusively in males. Only 5 cases have been reported in females till date. ts Majority (85%) of cases have been detected during the first year of life.912 Only 3 cases have been reported in adultsY 3.14The youngest reported patient was 5 hrs old tS and the oldest was of 40 years. Both the cases under presentation were males and were 3 months, 7 days old respectively. We have encountered only 2 patients of gastric tcratoma over a period of 10 years, out of 121 cases of teratomas in children (1.6%). These patients usually present with complaints of abdominal distension or presence
The othcr modality used in diagnosis is sonography and Magnetic Resonance imaging. Our both the cases showed calcification on plain x-ray film of abdomcn. However, the diagnosis was established in both cases only at laparotomy. These tumours can arise from any part of stomach with a preponderance for anterior and posterior walls. The later being slightly commoner. )1.~7 Majority of ruinous are exogastrie. 3,u.~3,tS~3~ But sometimes a small endogastric component may be present as well.2tz~ At other times these may be entirely endogastric? 6.32 The last 2 types may manifest as G.I. bleed. Rarely gastric teratoma may" extend into the mcdiastinum ~6a3-u and present with cyanosis and cough. In our case No. 1, the tumour was entirely exogastric arising from the posterior wall of stomach and the case No 2 was mainly exogastric with a small cndogastric component arising from the anterior wall of body of stomach close to cardiac end, which accounted for G.I. bleed. Local excision of tumour with a primary repair of stomach is the treatment of choice) 7"2~.29"3~Partial gastrcctomy )3a~5,~ and rarely total gastrectomy32 may bc required The turnout size can be variable. The smallest size of tumour reported so far has been only 100 grns37 and the largest sized tumour has becn our Ist case with 1120 gins wcight. Previously reported largest tumour was 990 gms in weight.3~Thcse tumours are always benign but peritoneal gliomatosis
CI.INICAI. BRII-I"S : GAS'I'RIC "I F.IG'~'I'OMA- REVIEW OF LITERA'IL;RE has been sccn 10 m o n t h s following r e m o v a l of a gastric t c r a t o m a in an infant, u O u r 2nd case is also unique in the sense that the histopa~,hological examination o f the t u m o u r showed p r e m a l i g n a n t changes. However, the child is well 16 months after surgery ~,nd is b e i n g followed iJp regularly for dclaycd a p p e a r a n c e o f r c c u r r c n c e o r gliomatosis. REI.'ERENCES I. Cairo MS, Grosfeld JL, Wectman RN. Gastric teratoma-unusual cause of bleeding of the upper gastrointestinal tract in the new born. Pediatr 198I; 67 : 721-726. 2. Esposite G, Cigliano B, Paludelto R. Abdomino-thoracic gastric tcratoma in a female new born infant. J Pediatr Sut~, 1983; 18 : 304-305. 3. Montelve-Marin A, Villacampa-Ramos CE, Rivera-Leol E et al. Gastric tcratoma in a female new born infant. Bol Med lIosp hirant M~r 1987; 44 : 349-353. 4. Purvis JM, Miller RE, Blumenthal BI. Gastric tcratoma, first reported in a female. J PediatrSur~ 1979; 14 : 86-87. 5. Sanacak ME. Kale G, B'uy Ukpamuk Cu N et al. Gastric teratoma in children including the third reported female case. J Pediatr .~ha~, 1990; 25 : 681-684. 6. Eustcrrnan GB, Sentry EG. Benign tumours of stomach. Report of twenty seven cases..~;w~, Gynaecol Obstet 1922; 34 : 372378. 7. Tencnbaum D, Scart C, Brichion P e t al. Gastric teratoma disclosed by neonatal digestive hemorrhage. Paediatr 1987; 42 : 171-174. 8. Wedge J J, Grosfeld JL, Smith JP. Abdominal masses in the new born 63 cases. J Urol 1971; 106 : 770-775. 9. Collins DL, Black JH, Mullinger MM. Gastrectomy in early childhood. Am J Dis Child 1965; 109 : 149-154. It). Hally T, Dimler M, Hollier P. Gastric ter-
543
atoma with gastro intestinal bleeding. J PediatrSwg 1986; 21 : 949-950. tl. Matias IC, Huang YC. Gastric teratoma in infancy.Ann Surg 1973; 178 : 63t-636. 12. Satge O, Auge B, Philippie E et al. Gastric tcratoma in new born children. Ann Pediatr (Paris) 1990; 37 : 235-241. 13. Fadeeva NV, Sharer II. Teratoma of the stomach. Arkh. Pathol. 1960; 22 : 55. Quoted from Am1 Surg 1973; 178 : 631-636. 14. Gray SW, Johnson HL Jr, Skandalakis JE. Gastric tcratoma lil an adult with review of literature. South MedJ 1964; 57 : 1346. 15. Meadow SR. Gastric teratorna. Post Grad MedJ 1968; 44 : 183-185. 16. Goray GH, Jayaratne SA. Teratoma in a young infant. Arch Pathol 1959; 67 : 39--41. 17. Aspiroz JC, Valle EM, Herberth A F et al. Gastric teratoma in infants. A m J Sut~, 1974; 128 : 429-432. 18. Justrabe E, Levillain P, Michiels R et al. Digestive haemorrhage disclosing gastric teratoma. Apropos of a case and review oJ" literature. Arch Anat Cytol Pathol 1986; 34 : 237-240. 19. Ravi Kumar VR, Ragupathy R, Das L. Gastric teratoma in infant. J Pediatr Surg 1986; 21 : 948. 20. Grosfeld JL, Bettantine TBN, Baehner RL. Benign and malignant teratoma in child r e n - Analysis of 85 patients. Sut~,et), 1976; 80 : 297-305. 21. Atwell JD, Claireaux AE, Nixon WH. Teratoma of the stomach in new born. J PcdiatrSurg 1967; 2 : 197-204. 22. Earnshaw JJ. Gastric teratoma in infancy. J Coil SLII~ Edin 1985; 30 : 199-200. 23. Handelsman JC, Reinhoff WF, Ward GE. Benign tumours of the stomach in an infant.Am JDis ChiM 1955; 90 : 196-198. 24. Maipang T, Suthipintawang C, Suthipintawang S. Gastric teratoma a case report. J MedAssoc Thai 1984; 67 : 306-309. 25. Martinez Miravete MT, Ruiz Jim'enez Jl, Rogues Serradilla JL et al. Teratoma of gastric localization : report of a case. Ann Esp Pediatr 1990; 32 : 275-276.
544
TI 1E INDIAN JOUI,LNAI.OF PEDIATRICS
26. Mariuchi A, Nakayama A, Mute H et al. Gastric teratoma in children. A case report and review of literature Acta Pathol Jpn 1977; 27 : 49. 27. Moz~iconacci JG, Charritat JL, Labbe F et al. An unusual cause of hematomesis in the new born infant. Apropos of a case. Ann Pediatr (Paris) 1984; 31 : 321-324. 28. Nicdzwiecki G, Wood BP. Radiological cases of the month. Gastric tcratoma. Am J Din Child 1990; 144:1147-1148. 29. Paul M, Corray GM, Wickremisinghe SYDC. Teratoma of stomach. Br J Surg 1962; 50 : 154-156. 30. Sclman AN. Complex tridermal teratoma of stomach (Benign) : A case report. Am J Supg 1948; 59 : 567-570. 31. Sariana C, Silva Curvas A, Esparaza H. Teratoma tridermicodel estomagoen un ninode 45 diaseded tratado con exito por gastrectoma parcial. Bol Med lfosp blf 1958; 5 : 529. Quoted from Ann Surg 1973; 178 : 631-636.
Vol. 59, No. 4 32. De-Angelis VR. Gastric teratoma in a new born infant. Total gastrectomy with survival. Surgery 1969; 66 : 794-797. 33. Chiba T, Suzuki H, Hebiguchi T et al. Gastric teratoma extending into mediastinum. J PediatrSutg 1980; 15: 191-192. 34. Siddappa OS, Girish ML, Shanthaveerappa R. Gastric teratoma with thoracic extension in 2 year old boy. PediatrSurg bzt 1991; 6 : 390-392. 35. Lackner H, Urban C, Riccabona M e t al. Teratoma of the stomach in a 4 day old new born infant. Monat Schr Kindetheilkd 1990; 138 : 291-293. 36. Large HL, Williams M, Carlotle NC. Gastric triderrnal teratoma in infancy. Successful treatment by subtotal gastreetomy JAMA 1952; 149 : 824-826. 37. Polony M. Teratoma exogastrique. Mere Acad Cir 1936; 62 : 622. Quoted from Aim Surg 1973; 178 : 631-636. 38. Coulson WF. Peritoneal gliomatosis from a gastric teratoma. Am J Clin Patrol 1990; 94 : 87-89.
Counselling Concerns as Related to Familial Vesico-Ureteral Reflux in Two Siblings Vijay ~,umar, D. Ramesh and M.S. i~ao
Department of Urolohy, Kasturba Medical College and Hospital, Manipal The interest provoked by the discovery of familial vesico-ureteral reflux hitherto has been largely towards its genetic and screening implications. ~'2 In two symptomatic siblings requiring surgical correction concurrcntly, appropriate counselling challenges towards allaying lhe anxieties of parent and children involved during the detection, treatment and follow-up of this problem
were encountered, which are elaborated upon and discussed in this article. CASE R E P O R T A four year old boy and his nine year old sister were both brought by their parents to the Urology II O P D for similar complaints of recurrent high fever (40~ and rigor episodes with left flank colic of 8 months
Indian J Pcdiatr 1992; 59 : 5 4 1 - 5 4 7 i
G a s t r i c T e r a t o m a - Review of L i t e r a t u r e A.N. Gangnpadhyay, S.K. Pandit, A. Sinlm, S.C. Gopal and S. Khanna*
Departments of Pediatric Surgery, and *Pathology, hastitute of Medical Sciences, Banaras Hindu University, Varanasi Gastric tcratoma is an extremely rare tumour of infancy and childhood? It is almost exclusively found in malcs and rarcly found in females, t5 The tumours are always benign. CASE REPORT Case 1 A male child of 3 months was admitted in children's Hospital at B.H.U., Varanasi on Fcbruary 1981 with progressive abdominal distension and history of failure to thrive since birth. Child was anaemic and underwcight with a palpable firm mass in left uppcr half of abdomen with a restricted mobility. Plain X-ray film of abdomen showed soft tissue mass with patchy calcification. Intravenous urography showed downward and mcdial displacemcnt of left pelvicalyceal system. Barium study of uppcr GIT showed anterior and upward displacement of Ihc stomach. On exploration, the tumour was arising from the postcrior surface and greater curvature of fundus and body of stomach and was exogastric. Turnour was excised akmg with a portion of greater curvature of stomach. The tumour was weighing 1120 gms (Figure 1). Histology showed a benign picture of tcratoma. Case 2 A male infant of 7 days was admitted on November 19")0 to our hospital with complaints of abdc~minal distension and he-
Fig. l.Cut surface of the excised specimen of gastric teratoma in case no. 1 weighing 1120 g. matcmesis and malcna. The child was anaemic and had a marked abdominal distension with a mass palpable in the upper half of abdomcn, with a variable consistency. Plain X-ray film of abdomen showed soft tissue mass in upper abdomen with few areas of calcification. Ultrasonography showed an extra rcnal mass which was partly echofree and partly echogenic but exact anatomical location was not clear. Intravenous Pyelogram (I.V.P.) showed bilateral hydroncphrosis and displacement of kidneys and ureters. Exploratory laparotomy showed a tumour arising from the anterior surface of the body and fundus of the stomach. Tumour had a small endogastric component as well (Figure 2). Tumour weighed 500 gms and the histopathology showed teratoma with prcmalignant changes. Child is how-
5,12
Tl IE INDIAN J t ) U R N A I , ()F P E D I A T R I C S
Vol. 59, No. 4
of a lump) m6 Patients may however also prcsent with gastrointestinal bleeding occasionallyl'7'~~ as encountered in our second case. Plain X-ray film of abdomcn shows either calcification or presence of a calcified mass in more than 50% of c a s e s , lt'19 Sometimes teeth or bone may be s e e n . 2~
Fig. 2.Excised gastric teratoma weighing 500 g of case no. 2 showing mainly cxo-gastric with a small endogastric component below, ('[' indqcating the linc of demarcation). cvcr progrcssing well and has gained weight. DISCUSSION Gastric teratoma was described for the first time by Eusterman & Sentry in 1922 in a 31 year old male paticnt. 6 Since then 65 cases have been reported in the litcrature. Gastric tcratoma constitutes less than 1% of infant teratomas and about 1.6% of abdominal leratomas. 7`s It is found exclusively in males. Only 5 cases have been reported in females till date. ts Majority (85%) of cases have been detected during the first year of life.912 Only 3 cases have been reported in adultsY 3.14The youngest reported patient was 5 hrs old tS and the oldest was of 40 years. Both the cases under presentation were males and were 3 months, 7 days old respectively. We have encountered only 2 patients of gastric tcratoma over a period of 10 years, out of 121 cases of teratomas in children (1.6%). These patients usually present with complaints of abdominal distension or presence
The othcr modality used in diagnosis is sonography and Magnetic Resonance imaging. Our both the cases showed calcification on plain x-ray film of abdomcn. However, the diagnosis was established in both cases only at laparotomy. These tumours can arise from any part of stomach with a preponderance for anterior and posterior walls. The later being slightly commoner. )1.~7 Majority of ruinous are exogastrie. 3,u.~3,tS~3~ But sometimes a small endogastric component may be present as well.2tz~ At other times these may be entirely endogastric? 6.32 The last 2 types may manifest as G.I. bleed. Rarely gastric teratoma may" extend into the mcdiastinum ~6a3-u and present with cyanosis and cough. In our case No. 1, the tumour was entirely exogastric arising from the posterior wall of stomach and the case No 2 was mainly exogastric with a small cndogastric component arising from the anterior wall of body of stomach close to cardiac end, which accounted for G.I. bleed. Local excision of tumour with a primary repair of stomach is the treatment of choice) 7"2~.29"3~Partial gastrcctomy )3a~5,~ and rarely total gastrectomy32 may bc required The turnout size can be variable. The smallest size of tumour reported so far has been only 100 grns37 and the largest sized tumour has becn our Ist case with 1120 gins wcight. Previously reported largest tumour was 990 gms in weight.3~Thcse tumours are always benign but peritoneal gliomatosis
CI.INICAI. BRII-I"S : GAS'I'RIC "I F.IG'~'I'OMA- REVIEW OF LITERA'IL;RE has been sccn 10 m o n t h s following r e m o v a l of a gastric t c r a t o m a in an infant, u O u r 2nd case is also unique in the sense that the histopa~,hological examination o f the t u m o u r showed p r e m a l i g n a n t changes. However, the child is well 16 months after surgery ~,nd is b e i n g followed iJp regularly for dclaycd a p p e a r a n c e o f r c c u r r c n c e o r gliomatosis. REI.'ERENCES I. Cairo MS, Grosfeld JL, Wectman RN. Gastric teratoma-unusual cause of bleeding of the upper gastrointestinal tract in the new born. Pediatr 198I; 67 : 721-726. 2. Esposite G, Cigliano B, Paludelto R. Abdomino-thoracic gastric tcratoma in a female new born infant. J Pediatr Sut~, 1983; 18 : 304-305. 3. Montelve-Marin A, Villacampa-Ramos CE, Rivera-Leol E et al. Gastric tcratoma in a female new born infant. Bol Med lIosp hirant M~r 1987; 44 : 349-353. 4. Purvis JM, Miller RE, Blumenthal BI. Gastric tcratoma, first reported in a female. J PediatrSur~ 1979; 14 : 86-87. 5. Sanacak ME. Kale G, B'uy Ukpamuk Cu N et al. Gastric teratoma in children including the third reported female case. J Pediatr .~ha~, 1990; 25 : 681-684. 6. Eustcrrnan GB, Sentry EG. Benign tumours of stomach. Report of twenty seven cases..~;w~, Gynaecol Obstet 1922; 34 : 372378. 7. Tencnbaum D, Scart C, Brichion P e t al. Gastric teratoma disclosed by neonatal digestive hemorrhage. Paediatr 1987; 42 : 171-174. 8. Wedge J J, Grosfeld JL, Smith JP. Abdominal masses in the new born 63 cases. J Urol 1971; 106 : 770-775. 9. Collins DL, Black JH, Mullinger MM. Gastrectomy in early childhood. Am J Dis Child 1965; 109 : 149-154. It). Hally T, Dimler M, Hollier P. Gastric ter-
543
atoma with gastro intestinal bleeding. J PediatrSwg 1986; 21 : 949-950. tl. Matias IC, Huang YC. Gastric teratoma in infancy.Ann Surg 1973; 178 : 63t-636. 12. Satge O, Auge B, Philippie E et al. Gastric tcratoma in new born children. Ann Pediatr (Paris) 1990; 37 : 235-241. 13. Fadeeva NV, Sharer II. Teratoma of the stomach. Arkh. Pathol. 1960; 22 : 55. Quoted from Am1 Surg 1973; 178 : 631-636. 14. Gray SW, Johnson HL Jr, Skandalakis JE. Gastric tcratoma lil an adult with review of literature. South MedJ 1964; 57 : 1346. 15. Meadow SR. Gastric teratorna. Post Grad MedJ 1968; 44 : 183-185. 16. Goray GH, Jayaratne SA. Teratoma in a young infant. Arch Pathol 1959; 67 : 39--41. 17. Aspiroz JC, Valle EM, Herberth A F et al. Gastric teratoma in infants. A m J Sut~, 1974; 128 : 429-432. 18. Justrabe E, Levillain P, Michiels R et al. Digestive haemorrhage disclosing gastric teratoma. Apropos of a case and review oJ" literature. Arch Anat Cytol Pathol 1986; 34 : 237-240. 19. Ravi Kumar VR, Ragupathy R, Das L. Gastric teratoma in infant. J Pediatr Surg 1986; 21 : 948. 20. Grosfeld JL, Bettantine TBN, Baehner RL. Benign and malignant teratoma in child r e n - Analysis of 85 patients. Sut~,et), 1976; 80 : 297-305. 21. Atwell JD, Claireaux AE, Nixon WH. Teratoma of the stomach in new born. J PcdiatrSurg 1967; 2 : 197-204. 22. Earnshaw JJ. Gastric teratoma in infancy. J Coil SLII~ Edin 1985; 30 : 199-200. 23. Handelsman JC, Reinhoff WF, Ward GE. Benign tumours of the stomach in an infant.Am JDis ChiM 1955; 90 : 196-198. 24. Maipang T, Suthipintawang C, Suthipintawang S. Gastric teratoma a case report. J MedAssoc Thai 1984; 67 : 306-309. 25. Martinez Miravete MT, Ruiz Jim'enez Jl, Rogues Serradilla JL et al. Teratoma of gastric localization : report of a case. Ann Esp Pediatr 1990; 32 : 275-276.
544
TI 1E INDIAN JOUI,LNAI.OF PEDIATRICS
26. Mariuchi A, Nakayama A, Mute H et al. Gastric teratoma in children. A case report and review of literature Acta Pathol Jpn 1977; 27 : 49. 27. Moz~iconacci JG, Charritat JL, Labbe F et al. An unusual cause of hematomesis in the new born infant. Apropos of a case. Ann Pediatr (Paris) 1984; 31 : 321-324. 28. Nicdzwiecki G, Wood BP. Radiological cases of the month. Gastric tcratoma. Am J Din Child 1990; 144:1147-1148. 29. Paul M, Corray GM, Wickremisinghe SYDC. Teratoma of stomach. Br J Surg 1962; 50 : 154-156. 30. Sclman AN. Complex tridermal teratoma of stomach (Benign) : A case report. Am J Supg 1948; 59 : 567-570. 31. Sariana C, Silva Curvas A, Esparaza H. Teratoma tridermicodel estomagoen un ninode 45 diaseded tratado con exito por gastrectoma parcial. Bol Med lfosp blf 1958; 5 : 529. Quoted from Ann Surg 1973; 178 : 631-636.
Vol. 59, No. 4 32. De-Angelis VR. Gastric teratoma in a new born infant. Total gastrectomy with survival. Surgery 1969; 66 : 794-797. 33. Chiba T, Suzuki H, Hebiguchi T et al. Gastric teratoma extending into mediastinum. J PediatrSutg 1980; 15: 191-192. 34. Siddappa OS, Girish ML, Shanthaveerappa R. Gastric teratoma with thoracic extension in 2 year old boy. PediatrSurg bzt 1991; 6 : 390-392. 35. Lackner H, Urban C, Riccabona M e t al. Teratoma of the stomach in a 4 day old new born infant. Monat Schr Kindetheilkd 1990; 138 : 291-293. 36. Large HL, Williams M, Carlotle NC. Gastric triderrnal teratoma in infancy. Successful treatment by subtotal gastreetomy JAMA 1952; 149 : 824-826. 37. Polony M. Teratoma exogastrique. Mere Acad Cir 1936; 62 : 622. Quoted from Aim Surg 1973; 178 : 631-636. 38. Coulson WF. Peritoneal gliomatosis from a gastric teratoma. Am J Clin Patrol 1990; 94 : 87-89.
Counselling Concerns as Related to Familial Vesico-Ureteral Reflux in Two Siblings Vijay ~,umar, D. Ramesh and M.S. i~ao
Department of Urolohy, Kasturba Medical College and Hospital, Manipal The interest provoked by the discovery of familial vesico-ureteral reflux hitherto has been largely towards its genetic and screening implications. ~'2 In two symptomatic siblings requiring surgical correction concurrcntly, appropriate counselling challenges towards allaying lhe anxieties of parent and children involved during the detection, treatment and follow-up of this problem
were encountered, which are elaborated upon and discussed in this article. CASE R E P O R T A four year old boy and his nine year old sister were both brought by their parents to the Urology II O P D for similar complaints of recurrent high fever (40~ and rigor episodes with left flank colic of 8 months
