Patient Presentation
A 17-year-old female came to clinic for her health maintenance visit. She was a senior in high school and was planning on living in the dormitories when she starts college the following year. There were no health concerns. The pertinent physical exam revealed a healthy female with normal vital signs and normal physical examination.

The diagnosis of a healthy female was made. “I recommend that you get the Meningitis B vaccine today. It helps to protect against a meningitis which is a bad brain infection. It can occur in group settings like dorms so we recommend it for college-bound students. You’ll need one now and one again after at least 6 months,” the pediatrician recommended. “Didn’t I already get the meningitis vaccine last year?” she asked. “Right. You did but that is a different vaccine. That one is for meningitis groups A,C, W and Y. Meningitis B is different, and was developed differently, so we do it separately. There is a combination vaccine with all 5 types in it, but I don’t have that one. There’s been some problems with insurances paying for the combination. Your insurance will pay for the separate Meningitis B vaccine. What questions do you have about it or meningitis?” he went on. After discussion with her and her parent, she agreed to all recommended routine health surveillance including HIV screening and all vaccines.

Discussion
Neisseria meningitidis is a major cause of morbidity and mortality including pneumonia, septicemia and meningitis. There are high case fatality and serious life-long complications for those that survive. There are 12 serotypes but A, B, C, W, X and Y cause almost all of the invasive meningococcal disease (IMD). The others are C, H, I, K, L, and Z. The epidemiology of which serotypes cause IMD is different geographically and changes over time. Most IMD cases are in children < 2 years of age, but in some countries there is also a small peak in late adolescence/early adulthood.

Crowded conditions especially when first exposed have a high risk of IMD including first year students in dormitories, military recruits and those exposed for events such as Hajj and Umrah pilgrimages. The Kingdom of Saudi Arabia requires vaccination against A,C,W,Y for these pilgrimages. Some health care providers will also recommend it for other global events such as the Olympics or World Cup Soccer because of crowded conditions. The 73rd World Health Assembly has approved a public health path to defeat meningitis by 2030.

Vaccines against A, C, W, and Y that are mainly used today are polysaccharide-conjugate vaccines.

Learning Point
Meningitis B vaccines “have been difficult to develop due to structural similarities of its capsular polysaccharide with human foetal neural cell adhesions modules, rendering it poorly immunogenic.” There was also the concern for inducing antoimmunity. It has taken more than 40 years to develop these effective vaccines.

In 2013, 4CMenB (Bexsero® from GSK) was approved again serotype B and started being used as part of the routine immunization schedule in the United Kingdom in 2015. It is a 4 component, recombinant, protein-based vaccine. In 2015, it was approved for use in the United states for 10-25 year olds. Since that time more countries are using it and another approved vaccine against serotype B, MenB-FHbp (Trumenba®, from Pfizer). PENMENVY® (from GSK) has serotypes A,B,C,W,Y antigens and was approved in February 2025 in the US.

The vaccines have been very effective including >80% effectiveness in infancy and protection lasting up to 3 years. They have been shown to be potentially effective against other serotypes, and in some studies to also be effective against nasal carriage. Protection is thought to be longer lasting in people > 5 years who receive the vaccine than those < 5 year olds. There is some data supporting additional protection against Neisseria gonorrhea as both organisms share some antigens.

Questions for Further Discussion
1. What meningococcal meningitis vaccines to you recommend and have available in your practice?
2. Where can you find vaccine schedules for other countries?
3. What are the different cerebrospinal fluid findings in different causes of meningitis? A review can be found here.
4. What causes encephalitis? A review can be found here.

Related Cases

Disease: Meningitis | Childhood Immunization

Symptom/Presentation: Health Maintenance and Disease Prevention

Specialty: Infectious Diseases | Preventive Medicine and Health Maintenance

Age: Teenager

To Learn More
To view pediatric review articles on this topic from the past year check PubMed.

Evidence-based medicine information on this topic can be found at SearchingPediatrics.com and the Cochrane Database of Systematic Reviews. Information prescriptions for patients can be found at MedlinePlus for these topics: Meningitis and Vaccine.

To view current news articles on this topic check Google News.

To view images related to this topic check Google Images.

To view videos related to this topic check YouTube Videos.

Rappuoli R, Pizza M, Masignani V, Vadivelu K. Meningococcal B vaccine (4CMenB): the journey from research to real world experience. Expert Review of Vaccines. 2018;17(12):1111-1121. doi:10.1080/14760584.2018.1547637

Garland JM. An Update on Meningococcal Vaccination. Rhode Island Medical Journal. Published online 2020.

Isitt C, Cosgrove CA, Ramsey ME, Ladhani SN, Success of 4CMenB in preventing meningococcal disease: evidence from real-world experience. Arch Dis Child 2020:105; 784-790.

Parikh SR, Campbell H, Bettinger JA, et al. The everchanging epidemiology of meningococcal disease worldwide and the potential for prevention through vaccination. Journal of Infection. 2020;81(4):483-498. doi:10.1016/j.jinf.2020.05.079

Meningitis. Accessed September 23, 2025. https://www.who.int/teams/immunization-vaccines-and-biologicals/diseases/meningitis

Author
Donna M. D’Alessandro, MD
Professor of Pediatrics, University of Iowa

PediatricEducation.org is taking a holiday break and will return on January 5, 2026. We appreciate your continued patronage and wish everyone a happy and safe holiday season and all the best in the New Year.

In the meantime, please take a look at the different Archives and Curriculum Maps listed at the top of the page.

Happy Holidays,

Donna D’Alessandro and Michael D’Alessandro, curators.

Patient Presentation
Pediatric residents and their attending pediatrician were discussing a new adolescent oncology patient admission. The teen was diagnosed with lymphoma after presenting with cough, fever and fatigue, and who had mediastinal lymphadenopathy. The attending remarked that lymphoma was common in this age group and also a common cause of anterior mediastinal tumors. “Remember your 4T’s, but thymoma is rare,” he said. “Then why do we always talk about it so much?” asked one of the residents. “I think that’s funny too. Thymoma is rare in kids, but more common in adults. I always think about tumors starting with what is the likely organ it is arising from, then what organs are around in that space like the mediastinum, lungs, abdomen etc. Then what else commonly would metastasize to this area, and then of course, there is always bones and soft tissues that can have tumors arise from them like sarcomas or lipomas or hemangiomas. In this case, the thymus is one of those organs in the area and therefore you have to think about it as a potential cause. Oh, I should also throw in, remember to include infections like tuberculosis or fungal infections infiltrating into tissues which can look like masses, or even diseases like sarcoid. Less common, but like thymomas you should think about potential causes, although we start to work up more likely causes first just because they occur more often. Rare diseases happen rarely but do happen. In this patient’s case, he has mediastinal adenopathy, but also other nodes that we were able to more easily biopsy and therefore make the lymphoma diagnosis,” he discussed.

Figure 149 shows Hodgkin Lymphoma

Discussion
Thymomas are rare pediatric tumors. They can present at all ages from infancy to > 90 years but most occur in the 4th to 5th decades with 10% of thymomas diagnosed in those in the pediatric age range. There are approximately 80 cases of pediatric thymomas in the literature based on a 2022 comprehensive literature review spanning 1985-2020. In this and a 2014 review, males are more commonly affected than females in the pediatric age range, but in adults the genders are about the same percentage or have a slight female predominance.

Thymomas are associated with paraneoplastic processes including presentation with myasthenia gravis. Of pediatric patients with thymomas, 5-15% have been reported as having myasthenia gravis. For adult patients with a thymoma, 30% will develop myasthenia gravis. For those adult patients presenting with myasthenia gravis, 10% will have a thymoma. Overall most thymomas are generally indolent and often present for workup of another condition. However mass effect in the chest (e.g. cough, dyspnea, superior vena cava syndrome) can be a presentation especially in small children.

Learning Point
Thymic tumors include:

Thymoma

Thymic carcinomas

Anterior mediastinal tumors are usually remembered by the 4T’s of thymoma, teratoma, thyroid and “terrible” lymphoma. Germ cell tumors and lymphomas are most common. The differential diagnosis includes:

• Germ cell tumors such as teratomas and a variety of benign and malignant tumors of different cell types
• Lymphoma – Hodgkin’s lymphoma is most common.
• Thymic neoplasms – 15% with thymoma being the most common (about 4% of pediatric mediastinal tumors).
• Aberrant thyroid tissue and goiter
• Parathyroid adenoma
• Hemangioma
• Lipomas
• Sarcomas

Questions for Further Discussion
1. Explain the function of the thymus?
2. What is the name of the radiologic sign which shows the thymus on an infant chest radiograph?
3. What are the different types of myasthenia gravis? A review can be found here.
4. Describe the mediastinal spaces? A review can be found here.
5. What are the most common pediatric tumors? A review can be found here.

Related Cases

Disease: Lymphoma | Thymus Cancer

Symptom/Presentation: Cough | Fatigue | Fever and Fever of Unknown Origin | Mass or Swelling

Specialty: Oncology

Age: Teenager

To Learn More
To view pediatric review articles on this topic from the past year check PubMed.

Evidence-based medicine information on this topic can be found at SearchingPediatrics.com and the Cochrane Database of Systematic Reviews.

Information prescriptions for patients can be found at MedlinePlus for these topics: Lymphoma, Thymus Cancer, and Myasthenia Gravis.

To view current news articles on this topic check Google News.

To view images related to this topic check Google Images.

To view videos related to this topic check YouTube Videos.

Yalcin B, Demir HA, Ciftci AO, et al. Thymomas in Childhood: 11 Cases From a Single Institution. Journal of Pediatric Hematology/Oncology. 2012;34(8):601-605. doi:10.1097/MPH.0b013e31825808e9

Fonseca AL, Ozgediz DE, Christison-Lagay ER, Detterbeck FC, Caty MG. Pediatric thymomas: report of two cases and comprehensive review of the literature. Pediatr Surg Int. 2014;30(3):275-286. doi:10.1007/s00383-013-3438-x

Rossi C, Zanelli M, Sanguedolce F, et al. Pediatric Thymoma: A Review and Update of the Literature. Diagnostics (Basel). 2022;12(9):2205. doi:10.3390/diagnostics12092205

Myasthenia gravis and congenital myasthenic syndromes. In: Handbook of Clinical Neurology. Vol 195. Elsevier; 2023:635-652. doi:10.1016/B978-0-323-98818-6.00010-8

Author
Donna M. D’Alessandro, MD
Professor of Pediatrics, University of Iowa

Patient Presentation
A former 34 week gestation male who was now 4 months corrected gestational age was seen for his health maintenance visit. He had transitioned to regular formula feeding at 2 months and was taking his bottle well. His mother had not attempted solid foods. He had good head control in a prone position and was making cooing sounds. He was not consistently rolling over or using his hands at midline. He was stooling and urinating freely. The past medical history was positive for an isolated epispadias.

The pertinent physical exam showed a happy male who was developmentally appropriate for a 2 month old and his corrected gestational age. His growth parameters showed him now to be caught up and on the CDC growth charts he was growing at the 10%. He had a normal physical examination except that the dorsal base of the penis was his urethral opening. A mild curvature to the phallus was also noted.

The diagnosis of of a healthy male, former premature infant with isolated epispadias was made. His mother said that the pediatric urologist was happy with his growth and therefore would be scheduling his surgery soon.

Discussion
The exstrophy-epispadias complex (EEC) is a spectrum of congenitally acquired malformations that affect the urogenital, gastrointestinal and musculoskeletal systems. The most common is classic bladder exstrophy (BE) which occurs in 2.2-3.3 per 100,000 live births. Males are more affected than females. In addition to epispadias, the bladder plate is exposed and lies outside the abdominal wall. Cloacal exstrophy (CE) is the severest form of EEC. It is usually associated with an omphalocoele with multiple organs extending beyond the abdominal wall and are covered by a tissue sac. There can be numerous additional anomalies within CE including kidney abnormalities, duplicated reproductive systems, imperforate anus, and spinal and pelvic bony abnormalities.

BE and CE treatment requires a multidisciplinary team that can plan and carry out the often extensive and multiple surgeries necessary and appropriate pre- and after-care to achieve goals along with the patient and family. As they are complex surgeries, they have a higher rate of anticipated and actual complications. The goals of treatment include urinary and bowel continence and normal organ system growth, normal kidney function, and normal sexual function along with normal psychosocial function. Particular goals may have more importance depending on the patient’s age. Genital hygiene may be more of an issue for a young school age child who needs assistance, whereas a teenager or young adult is likely to be more concerned with sexual functioning.

Initial surgeries are usually performed in young children. Longer-term data supports that youth and young adults who had EEC surgeries were overall satisfied with their parents’ decision to have the surgery(ies) performed. “No decisional regret was found in parents. Reinterventions were associated with a decline in satisfaction, as was a decrease in perceived penile length.” Males with EEC overall have shorter and wider phalluses. Phalloplasty can offer some help for some patients but does have a high complication rate. Females with EEC may have more pregnancy related problems including increased risk of urinary tract infections, miscarriages, and genital prolapse.

Learning Point
Isolated epispadias is the mildest form of EEC and occurs in about 1 per 200,000 births. The urethra is not fully formed and in males “… is open at the dorsal side of the short and curved phallus”, while in females the urethra lies between a bifid clitoris. As this is isolated, the repair is usually less extensive than with BE or CE, but still can have complications.

Questions for Further Discussion
1. How common is hypospadias? A review can be found here.
2. What is normal phallus size? A review can be found here
3. What are common causes of splayed urinary stream? A review can be found here

Related Cases

Disease: Epispadias | Penis Disorders

Symptom/Presentation: Health Maintenance and Disease Prevention

Specialty: Nephrology / Urology

Age: Infant

To Learn More
To view pediatric review articles on this topic from the past year check PubMed.

Evidence-based medicine information on this topic can be found at SearchingPediatrics.com and the Cochrane Database of Systematic Reviews. Information prescriptions for patients can be found at MedlinePlus for these topics: Penile Disorders and Urethral Disorders.

To view current news articles on this topic check Google News.

To view images related to this topic check Google Images.

To view videos related to this topic check YouTube Videos.

Dunn EA, Kasprenski M, Facciola J, et al. Anatomy of Classic Bladder Exstrophy: MRI Findings and Surgical Correlation. Curr Urol Rep. 2019;20(9):1-7. doi:10.1007/s11934-019-0916-2

Sinatti C, Schechter MY, Spinoit AF, Hoebeke P. Long-term outcome of urethral and genital reconstruction in hypospadias and exstrophy-epispadias complex. Curr Opin Urol. 2021;31(5):480-485. doi:10.1097/MOU.0000000000000920

Haddad E, Hayes LC, Price D, Vallery CG, Somers M, Borer JG. Ensuring our exstrophy-epispadias complex patients and families thrive. Pediatr Nephrol. 2024;39(2):371-382. doi:10.1007/s00467-023-06049-y

Author
Donna M. D’Alessandro, MD
Professor of Pediatrics, University of Iowa