ILOILO MISSION HOSPITAL

DEPARTMENT OF PEDIATRICS

“ MIS C”

Presented by:
PGI Buhay, Lemuel Nes
PGI Casuncad, Merry Joy
PGI Dimacutac, Maria Francesca
PGI Gonzaga, Ed Marie
PGI Magalona, Lois Esther
PGI Pacheco, Diadem Anne

Resident in Charge:
Dr. Raiza B. Hisancha
OBJECTIVES

General:

To present a case of 16 years old, female who came in due to Jaundice and Fever

Specific:
1. To review the history, clinical manifestations, and differential diagnoses of
the patient with Jaundice
2. To discuss the incidence and pathophysiology of MIS - C secondary to
COVID 19 Infection and Epstein Barr Virus
3. To discuss the management and prognosis of MIS - C secondary to COVID 19
Infection and Epstein Barr Virus
 CASE

General Data:
Name: S.J
Age: 16 y/o
Birthday: December 24, 2007
Civil Status: Single
Address: Sibalom, Antique
Religion: Roman Catholic
Nationality: Filipino
Date of Admission: May 4, 2024
Time of Admission: 7:30 PM

Chief Complaint : “Jaundice and Fever”

History of Present Illness:

13 days prior to admission, patient had onset of cervical bilateral lymphadenopathies,

tender to touch, no note of fever, no other signs and symptoms associated. No medications
taken, no consult was done.

12 days prior to admission, patient had sudden onset of intermittent fever with
maximum temperature of 38०C, patient took Paracetamol 1 tablet with note of slight relief. In
the interim, there was persistence of intermittent fever with a maximum temperature of 38०C
usually occurring at night. No other medications taken, no consult was done.

4 days prior to admission, due to persistence of intermittent fever, now associated with
tea colored urine patient sought consult with PP, and was requested with the following
laboratories: CBC, which revealed (+) leukocytosis and (+) lymphocytosis, Urinalysis which
revealed glucosoria (2+), and Leukocytosis (WBC 10-25). Patient was then managed as a case of
Urinary Tract Infection and was given the following medications: 1. Cefuroxime 500mg BID,
2. Omeprazole 40mg OD pre breakfast.

3 days prior to admission, there was onset of epigastric pain rated 7/10 upon palpation,
not aggravated nor relieved by food intake, associated with bloatedness, occasional retching,
icteric sclerae, decrease in appetite, and persistence of intermittent fever. No vomiting, no loose
stools, no other signs and symptoms associated. Patient made a teleconsult to PP via SMS, and
was requested with SGPT which revealed 474.6 U/L elevated and whole abdomen ultrasound.

2 days prior to admission, now with onset of generalized jaundice, still with
intermittent fever, whole abdomen ultrasound was done revealing: Diffuse Hepatocellular
Disease with Mild Hepatomegaly, Mild splenomegaly. Patient was subsequently admitted at a
tertiary hospital (AMC) where other laboratories were requested. Patient was started with
Ceftriaxone (37mkday) 2 g IV OD x 3 days, Omeprazole 40mg 1 cap OD pre BF and Paracetamol
500mg 1 tab q6H PRN for fever.

1 day prior to admission at her 2nd hospital day, still with persistence of above
mentioned signs and symptoms, patient was referred to Gastro - IM and was requested with
Whole Abdominal CT Scan, other laboratories were taken revealing persistence of glucosuria in
urinalysis, FBS and HbA1C elevated. Patient was started with Metronidazole 40 mg IV q8H x 6
doses, UDCA 500mg OD x 3 days, Insulin 5 units -STAT, maintained on Biphasic insulin SQ (12
units Pre BF; 6 units Pre- Dinner), with CBG monitoring. Patient was then referred to Gastro -
Pedia.

On the day of admission, due to unavailability of Gastro - Pedia at the said hospital,
patient was referred and brought to this institution for further management.

Past Medical History:

(+) Childhood Asthma (2-3 yo)
- Seretide BID - PRN
(+) Acanthosis Negricans (11-12yo)
- requested FBS - Normal
(-) Food and Drug Allergy

Family History:
This is the family genogram of patient J.S, Diabetes Mellitus and Nasopharyngeal carcinoma is
noted on the maternal side, while Hypertension is noted on the paternal side. RHD is noted with
her sibling. The patient lives with parents and 1 sibling.

Personal,Social,and Environmental History:

Lives in a rural area 5-10 km away from the neighborhood, their house is a one storey
cemented bungalow house with 3 bedrooms, well lit and with adequate ventilation. Their
water supply comes from a deep well (Tuburan) used for drinking mixed with Purified whenever
available and is used for cleaning and bathing. Regular waste disposal is by burning, with their
septic tank that is 10 feet away from their house.
Her mother is a housewife and her father is a Seafarer who is the breadwinner of the
family.

HOME Lives with parents and 1 sibling with good

relationship, 4 household members

EDUCATION Grade 10 student, at Basilon National High School ,

with Honors, and no history of bullying

ACTIVITIES Reads books as her hobby, browsing cellphone as

her past time with usual screen time of 1 hour

DRUGS No history of drug, alcohol, smoke use/intake

(+) exposure to father 40 pack per year smoker

SEXUALITY No gender confusion, homosexual, no history of

sexual contact, (-) past relationships

SUICIDALITY/SAFETY No suicidal/homicidal tendecies

OBGYNE History:

OB SCORE: G0

LMP May 4, 2024

PMP April 10,2024

 MENSTRUAL HISTORY

Menarche 12 years old

Interval Regular

Duration 4-5 days

Amount 2-3 pads/moderately-fully soaked

Symptoms (+) Dysmenorrhea

Relieved by warm compress and
Hyoscine-N-butylbromide + Paracetamol

PHYSICAL EXAMINATION

Vital Signs Anthropometric Measurements

Temperature: 37.8 Weight: 66 kg

P: 129 beats/min Height: 155

R: 21 breaths/min BMI: 27.5 (Overweight)

BP: 120/80 mmHg IBW: 53.5

O2 Sat: 98% AG: 85cm

General Survey
● Awake, ambulatory, not in cardiopulmonary distress

HEENT
● Icteric Sclerae, pinkish conjunctiva, no eye discharges, isocoric pupils, 2-3 mm
● Non sunken eyeballs
● Non-hyperemic non-enlarged tonsils
● (+) cervical lymphadenopathies (.5-1mm)
● Dry lips moist tongue

Chest/ Lungs
● Symmetrical chest expansion, clear breath sounds

Heart
● Adynamic precordium, regular cardiac rate and rhythm
Abdomen
● Soft Flabby, normoactive, nontender abdomen, non tympanitic
● (+) tenderness at the epigastric area
● Liver span 5cm mid sternal, 2 fingerbreadths below the rib, midclavicular

Extremities
● Grossly normal extremities, full peripheral pulses

CNS
● intact cranial nerves, (-) meningeal and cerebellar sign
● DTRs 2+ Sensory 100% Motor 5/5

Admitting Impression

T/C Autoimmune Hepatitis vs Kawasaki Disease; Acalculous Cholecystitis probably secondary to

Viral Infection; Electrolyte Imbalance (Hyponatremia, Hypokalemia); Metabolic Associated
Fatty Liver Disease; Diabetes Mellitus Type II

COURSE IN THE WARDS

5/5/24 Day 13 of Illness > Add PBS on next blood extraction

AM T: 37.2 -37.8 (37.2) LF: 9PM 37.8 > Abdominal girth and weight
HD 1 P: 95 bpm monitoring Pre BF
R: 20 cpm > Hold Ceftriaxone shift to
BP: 100/60 Ciprofloxacin 200mg IVTT q12H ANST
O2: 99% > consume IV Metronidazole then shift
to oral 500mg 1 tab TID with food
(+) icteric sclerae
(+) puffy eyelids
(+) Bilateral CLADS
(+) generalized jaundice
(+) epigastric tenderness
(+) Muphy sign
(+) palmar erythema

Awake, active, comfortable not in

CPD,ictereic sclerae, moist lips and
tongue, SCE, CBS, AP, RCRR, soft
flabby abdomen, (+) epigastric
tenderness, GNE with full pulses

5/6/24 Day 14 of Illness > Start Insulin Aspart (Novorapid) 8

HD 2 Day 3 of Menses units SQ pre-meals
 T: 36-37.8 (36) Wt: 64kg > CBG monitoring pre- injection and 2H
P: 75-108 (75) bpm AG: 87cm postprandial
R: 20 cpm > CBG and insulin recording
BP: 90/60 -120/80 (110/70) > start DHA and EPA (Omega) 2 cap
O2: 95-98% (98%) 2x a day
(+) 1 episode of abdominal discomfort
prior to BM
(+) icteric sclerae
(+) puffy eyelids
(+) Bilateral CLADS 1.5 - 2cm
(+) generalized jaundice
(+) epigastric tenderness
(+) Muphy sign
(+) palmar erythema

Awake, active, comfortable not in

CPD,ictereic sclerae, moist lips and
tongue, SCE, CBS, AP, occ
tachycardia soft flabby abdomen, (+)
epigastric tenderness, GNE with full
pulses

5/7/24 15th Day of Illness >Increase Insulin to 9 units pre meals

HD 3 T: 36-37.3 (36) AG: 86 (87)cm >Adjust diet
P: 95-100(81) bpm >For D-dimer, ferritin, CRP, LDH, S.
R: 18-20 (20) cpm Alb, SGPT. SGOT, Trop I and CPK-MB,
BP: 100/60 - 110/70 (100/60) S. EBV IgG and IgM
O2: 96-98 (98)% >IVIG (VSV) gamma 100g
> Start Methylprednisolone 130mg
(+) Icteric sclerae IVTT q12H x 7 days then decrease to 4
(+) Bilateral CLAD tabs OD x 7 days then decrease to 2
(-) abdominal pain tabs OD x 7 days once IVIG is
(+) erythermatous non pruritic available
maculopapular rash > Start Aspirin 80mg/tab 2 tabs q 12H

Awake, active, comfortable not in

CPD,ictereic sclerae, dry lips, moist
tongue, (+) multiple CLAD, SCE, CBS,
AP, RCRR, soft flabby nontender
abdomen, GNE with full pulses

5/8/24 Day 16 of Illness > For T3, T4, and TSH

HD 4 Day 2 Afebrile > Shift IV to Ciprofloxacin to
Last day of Menses Ciprofloxacin 500mg/tab 1 tab BID
T: 36-36.7 (36.4) LF: 5/6 37.8 (12MN) > For Urine KOH
P: 80-93 (88)bpm AG: 87 (88) > Start Vitamin D3 1000 IU/capsule 1
R: 19-20 (20)cpm cap BID
 BP: 90/60-110/80 (90/60) > Start Vitamin C + ZInc tablet 1 tab
O2: 99% OD
> Start Methylprednisolone 65mg IV to
(+) decreasing generalized jaundice run for 1 H Q12H x 5 days
(+) erythematous non pruritic > Give Methylprednisolone 62.5mg IV
maculopapular rash + 100cc PNSS x 1h Q12H x 5 days
(+) Bilateral CLAD > shift IVF to Heplock

Awake, active, comfortable not in

CPD,anictereic sclerae, moist lips and
tongue, (+)CLAD, SCE, CBS, AP,
RCRR, soft flabby non tender
abdomen,(+) decreasing generalized
jaundice, GNE with full pulses

5/9/24 Day 17 of Illness > Increase insulin to 9 units premeals

HD 5 Day 3 Afebrile ● CBG1 50 mg/dLadd 1 unit
T: 36-36.7 (36.4) LF: 5/6 37.8 (12MN) ● CBG 250mg/dLadd 2 units
P: 80-93 (88)bpm AG: 87 (88) ● CBG 350mg/dL add 3 units
R: 19-20 (20)cpm ● CBG 450mg/dL add 4 units
BP: 90/60-110/80 (90/60) > Family conference done
O2: 99% > Revise Methylprednisone to 65 mg IV
+ 100cc PNSS to run for 1 hr Q12H to
(+) decreasing generalized jaundice complete x 3 days (5/8-5/11)
(+) erythematous non pruritic > Methylprednisolone 16mg/tab 2 tab
maculopapular rash BID x 7days (5/11-5/18)
(+) Bilateral CLAD >Methylprednisolone 16mg/tab 1 tab
OD x 7 days (5/26-6/1) D/C thereafter
Awake, active, comfortable not in give in full stomach
CPD,anicteric sclerae, moist lips and >Continue Aspirin 80mg/tab 2 tabs BID
tongue, (+)CLAD, SCE, CBS, AP, after meals x 8 weeks (5/8-7/3)
RCRR, soft flabby non tender > Repeat 2D ECHO on the 8th week
abdomen,(+) decreasing generalized > Repeat labs on D3 of
jaundice, GNE with full pulses Methylprednisolone
● SGPT, B1B2
● Prorime, CBC, Plt
● D-dimer, Ferritin, Fibrinogen
● LDH, CRP, ESR
> For PPD
> For C3, ANA

5/10/24 Day 18 of Illness > for urinalysis, ANA, and Coombs test
HD 6 Day 4 Afebrile > Continue previous medications
T: 36-37 Wt 64 (64) kg > Will monitor patient
P: 60-79 bpm AG: 87 (88) cm
R: 20-21 cpm
BP: 60/70-90/100 (90/60)
O2: 97-99%
 (+) decreasing generalized jaundice
(+) Minimal periorbital edema
(+) decreasing erythematous rash on
cheeks
(+) Multiple CLAD 1x 1.5cm

Awake, active, comfortable not in

CPD,anictereic sclerae, moist lips and
tongue, (+)CLAD, SCE, CBS, AP,
RCRR, soft flabby non tender
abdomen,(+) decreasing generalized
jaundice, GNE with full pulses

5/11/24 Day 19 of Illness > For IVIG however parents opted to

HD 7 Day 5 Afebrile HOLD due to financial constraints
T: 36(36) Wt 63 (64) kg > continue methyprednisone as
P: 60-73 (60) bpm AG: 81 (83) cm ordered
R: 20-21 (20) cpm > Continue Aspirin as ordered
BP: 90/60-110/70 (110/70) > For repeat 2D ECHO on 8th week of
O2: 97-99% Aspirin
> Complete Oral Metronidazole and
(+) decreasing generalized jaundice Ciprofloxacin x 10 days then
(+)palatal ulcers discontinue
(+) decreasing erythematous rash on > Ok for discharge under
cheeks (Dr. Faulan) Pedi - Infectious
(+) Multiple CLAD 1x 1.5cm

Awake, active, comfortable not in

CPD,anictereic sclerae, moist lips and
tongue, (+)CLAD, SCE, CBS, AP,
RCRR, soft flabby non tender
abdomen,(+) decreasing generalized
jaundice, GNE with full pulses

5/12/24 T: 36-36.1(36) Wt 64 (64) kg > Decrease Methylpreednisolone to 1

HD 8 P: 62-85 (85) bpm AG: 87 (88) cm tab TID
R: 20 cpm >No contraindications for dsicharge
BP: 90/60-110/60 (110/60) Rheuma standpoint
O2: 97-99 (98)% > Advise to use sunblock with SPF 50
and above
(+) decreasing generalized jaundice > May carry out ANA panel
(-)palatal ulcers > Not considering SLE - Rheuma
(+) decreasing erythematous rash on standpoint
cheeks
(+) Multiple CLAD 1x 1.5cm

Awake, active, comfortable not in

 CPD,anictereic sclerae, moist lips and
tongue, (+)CLAD, SCE, CBS, AP,
RCRR, soft flabby non tender
abdomen,(+) decreasing generalized
jaundice, GNE with full pulses

5/13/24 Day 19 of Illness > Increase Insulin Aspart (Novorapid)

HD 9 Day 5 Afebrile 12 units pre meals
T: 36 Wt 64 (64) kg > Shift pre dinner to Insulin
P: 60-71 (60) bpm AG: 87 (88) cm Degludec/Aspart (Ryzodeg) 15 units
R: 18-20 (20) cpm > Continue CBG monitoring
BP: 100/60 - 100/80 (100/60) > Continue Methylprednisone 16 mg 1
O2: 97-99 (97)% tab TID until 5/15/24 then adjust as
needed starting 5/16/24
(+) decreasing generalized jaundice > Follow up IgG - EBV result
(+) minimal rash on cheeks
(+) Multiple CLAD 1x 1.5cm

Awake, active, comfortable not in

CPD,anictereic sclerae, moist lips and
tongue, (+)CLAD, SCE, CBS, AP,
RCRR, soft flabby non tender
abdomen,(+) decreasing generalized
jaundice, GNE with full pulses

5/14/24 T: 36(36) AG 84 (86)cm > Hold evening dose of

HD10 P: 60-74 (74) bpm Methyprednisolone today
R: 20 cpm > Revise dose of methyprednisolone
BP: 100/60 -110/70 tomorrow AM 16 mg tab 1 tab BID with
O2: 99% food (Breakfast and dinner)

(+) decreasing generalized jaundice

(+) minimal rash on cheeks
(+) Multiple CLAD 1x 1.5cm

Awake, active, comfortable not in

CPD,anictereic sclerae, moist lips and
tongue, (+)CLAD, SCE, CBS, AP,
RCRR, soft flabby non tender
abdomen,(+) decreasing generalized
jaundice, GNE with full pulses

5/15/24 T: 36-36.6(36) > Further increase pre BF and pre

HD 11 P: 60-71 (61) bpm lunch insulin to 14 units, pre-dinner
R: 20 cpm insulin to Ryzodeq to 17 units
BP: 90/60-110/70 (110/70) > Ok for discharge once desired levels
O2: 97-99 (99)% of insulin is reached.
 > Continue Methyldopa 16 mg/tab 1
(+) decreasing generalized jaundice tab BID
(+) minimal rash on cheeks
(+) Multiple CLAD 1x 1.5cm

Awake, active, comfortable not in

CPD,anictereic sclerae, moist lips and
tongue, (+)CLAD, SCE, CBS, AP,
RCRR, soft flabby non tender
abdomen,(+) decreasing generalized
jaundice, GNE with full pulses

5/16/24 T: 36-36.5(36) > Decrease Methylprednisolone 26mg

HD 12 P: 52-75 (52) bpm tab, ½ tab BID
R: 18-20(18) cpm > May go home per request
BP: 90/60-100/60 (90/60) > Home meds (ENDO)
O2: 96-99 (98)% ● Insulin aspart 14 units pre BF
and pre lunch SQ
(-) generalized jaundice ● Insulin degludec/ aspart 17
(-) maculopapular rash units pre dinner
● Multivitamins with Vit C + Zinc +
Awake, active, comfortable not in Fe and Folic Acid 1 tab OD
CPD,anictereic sclerae, moist lips and > CBG monitoring before each insulin
tongue, SCE, CBS, AP, RCRR, soft injection & 2 hours post meals
flabby non tender abdomen,GNE with > Adjust insulin Aspart according blood
full pulses glucose if blood glucose
● > 159mg/dL add I unit
● > 250 mg/dL add 2 units
● > 350 mg/dL add 3 units
● > 450 mg/dL add 4 units
● > 550 mg/dL add 5 units
> Ff up after 1 week May 24 RM 233 at
SPICE Building SPH
> May go home
> Watch out for recurrence of jaundice
and abdominal pain
> Home Medications:
● Metghylprenisolone 16mg/tab ½
tab BID until 5/25/24
● Methylprednisolone 16mg/tab ½
tab OD until 5/26 - 6/1/24
● Aspirin 80mg/tab 1 tab Q12H to
complete x 8 weeks
> Repeat 2D ECHO on the 8th week of
Aspirin
> Clinic ff up with Dr. Resurrecion-
Antique
5/17/24 T: 36.3 > Home Medications:
HD 13 P: 68 bpm ● Metghylprenisolone 16mg/tab ½
R: 21 cpm tab BID until 5/25/24
BP: 90/60 mmHg ● Methylprednisolone 16mg/tab ½
O2: 98% tab OD until 5/26 - 6/1/24
● Aspirin 80mg/tab 1 tab Q12H to
(-) generalized jaundice complete x 8 weeks
(-) maculopapular rash > Repeat 2D ECHO on the 8th week of
Aspirin
Awake, active, comfortable not in > Clinic ff up with Dr. Resurrecion-
CPD,anictereic sclerae, moist lips and Antique
tongue, SCE, CBS, AP, RCRR, soft
flabby non tender abdomen,GNE with
full pulses

FINAL DIAGNOSIS

Multisystem Inflammatory Syndrome in Children (MIS-C) secondary to COVID -19 Infection;

Epstein - Barr Virus (EBV) Co - Infection; Diabetes Mellitus most probably Type II
 APPENDICES

HEMATOLOGY

Examination Result Reference Value Interpretation

COMPLETE BLOOD COUNT

Hemoglobin 130 g/L 123-153 Normal

Hematocrit 0.373 vol.fr. 0.38-0.470 Normal

Red Blood Cells 4.37 10^2/L 4.10-5.10 Normal

White Blood Cells 14.28 10^95/L 4.40-11.30 Leukocytosis

DIFFERENTIAL COUNT

Neutrophil 0% 0.500-0.700 Normal

Segmenter

Stab 0% 0.00-0.05 Normal

Eosinophil 0.003% 0.005-0.050 Normal

Basophil 0% 0.000-0.010 Normal

Lymphocyte 0.620% 0.200-0.400 Lymphocytosis

Monocyte 0.078% 0.030-0.120 Normal

ERYTHROCYTE INDICES

Mean Corpuscular 85.4 fL 80-96 Normal

Volume (MCV)

Mean Corpuscular 29.7 pg 27-33 Normal

Hemoglobin (MCH)

Mean Corpuscular 348 g/dL 320-360 Normal

Hemoglobin
Concentration
(MCHC)

PLATELET COUNT 208 10^9/L 150-450 Normal

 COAGULATION STUDIES

Examination Result Reference Value Interpretation

Prothrombin Time (PT)

Percent Activity 84.5% 70-100 % Normal

Patient 12.7 seconds 9.1 - 12.1 seconds Prolonged

INR 1.09 0.2 - 1.2 Normal

CLINICAL CHEMISTRY

Examination Result Reference Value Interpretation

ELECTROLYTES

Sodium 133 135-148 Hyponatremia

(Def: 409.2)

Potassium 3.4 3.5-5.3 Hypokalcemia

Examination Result Reference Value Interpretation

ALT/SGPT 474.6 U/L < = 31.0 21.5 x Elevated

AST/ SGOT 213.40 U/L UP to 32 3.2 x Elevated

Alkaline Phosphatase 233.00 35 -104 2.45 x Elevated

Anti HCV Negative

HbsAg Non - Reactive

Anti HAV IgM Non- Reactive

BUN 2.53 1.8-6.4 Normal

CREA 77.10 45-84 Normal

Examination Result Reference Value Interpretation

Total Bilirubin 263.6 (15.41) Up to 21 Hyperbilirubinemia

(18.3 x Elevated)

Direct Bilirubin 224.6 (13.13) Up to 5 Hyperbilirubinemia

(31.2 x Elevated)

Indirect Bilirubin 39.00 (2.28) Up to 14 Normal

Examination Result Reference Value Interpretation

Procalcitonin < 0.05 < 0.01 ng/mL Normal

Ferritin > 1000 13-150 ng/mL Hemochromatosis

(5.81 x Elevated)

FBS 14.83 3.3 - 5.5mmol/L Hyperglycemia

HbA1c 7.80 4.3-6.4% Diabetes

Amylase 26.80 28-100 Normal

Examination Result Reference Value Interpretation

Typhidot IgG Positive Latent Infection

Typhidot IgM Negative No current Infection

 CLINICAL MICROSCOPY

Examination Result Interpretation

Physical Properties

Color Dark yellow

Transparency Slightly Hazy

Reaction 5.0

Specific Gravity 1.025

Chemical Examination

Glucose Positive (2+) Glycosuria

Protein Negative

Microscopic Findings

WBC Pus Cells 10-25 Leukocytosis

RBC Red Cells 5-10 Hematuria

Squamous Cells Many Contaminated

Renal Cells None

Bacteria Few

Mucus Threads Few

Yeasts Cells None

 CHEST X-RAY REPORT

Impression Thoracic Dextroscoliosis

WHOLE ABDOMEN ULTRASOUND

Impression ● Diffuse Hepatocellular Disease with Mild Hepatomegaly

● Mild Splenomegaly
● Normal Biliary Tree, Gallbladder, Pancreas ultrasonically

WHOLE ABDOMEN CT SCAN

Impression ● Hepatosplenomegaly with fatty parenchyma

● Minimal pericholecystic and posterior cul-de-sac fluid
collection
● To rule out Acalculous Cholecystitis
● Nonspecific Bilateral dense renal medullary sign
differentials include medullary nephrocalcinosis,
medications, normal and dehydration
● Para aortic lymphadenopathies
● Retroverted uterus with minimal endometrial fluid
collection
● Nabothian cysts
● Minimal Ascites
● Schmorl’s nodes L2, L3,and L4
● Thoracic dextroscoliosis