Leukemic arthritis

Paraneoplastic Sacroiliitis: A Masquerade of Inflammatory Arthritis in Leukemia

Leukemic arthritis is a rare but clinically significant presentation of leukemia, often resembling inflammatory or autoimmune arthritis. Axial joint involvement, particularly sacroiliitis, is an uncommon manifestation and can mislead clinicians, delaying the diagnosis of the underlying hematologic malignancy. We present the case of a 34-year-old woman with persistent low back pain, initially diagnosed as sacroiliitis and treated with conventional therapies. Despite partial symptom relief with nonsteroidal anti-inflammatory drugs and corticosteroids, her condition worsened, leading to further evaluation. Subsequent laboratory tests revealed leukocytosis and anemia, and a peripheral blood smear confirmed leukemic infiltration. The final diagnosis of paraneoplastic sacroiliitis secondary to acute leukemia was established. This case highlights the importance of considering malignancy in patients presenting with refractory arthritis, particularly when symptoms are atypical or fail to respond to standard treatments. Early recognition and prompt initiation of chemotherapy can significantly improve clinical outcomes.​.

Acute Promyelocytic Leukemia Masquerading as Sero-negative Polyarthritis: Case Report

Musculoskeletal manifestations as the sole presentation in acute leukemia is rare in adults. Acute promyelocytic leukemia (APML) is a subtype of acute myeloid leukemia (AML) with reported incidence of 10 to 15% of total AML cases. APML presenting as polyarticular arthritis has never been reported in the literature. We present an interesting case of 20-year-old male patient who manifested with polyarticular arthritis mainly of small joints as the initial presentation, followed by pancytopenia and eventually was diagnosed as a case of APML on bone marrow morphology and molecular analysis for PML-RARα transcript. He was successfully treated with all-trans-retinoic acid (ATRA) and arsenic trioxide (ATO). Arthritis also resolved with complete remission of APML. Arthritis in a case with pancytopenia should promptly be evaluated prior to treatment with steroids and anti-metabolites. Arthritis can be a presenting manifestation of APML and responds to prompt management of leukemia as in other cases of leukemic arthritis.

Inflammatory conditions of the pediatric hand and non-inflammatory mimics

Hand involvement can assume an outsized role in the perception and presentation of disease as a result of functional impairment, visual conspicuity and susceptibility to early structural damage. Rheumatologic referral for inflammatory conditions can be delayed because of assumptions of a traumatic, infectious or neoplastic etiology; conversely, initial rheumatologic evaluation might be pursued for many of the same non-inflammatory causes. This pictorial essay highlights inflammatory conditions affecting the pediatric hand, including juvenile idiopathic arthritis, infectious arthritis, systemic connective tissue disorders, and a variety of less common inflammatory diseases, as well as non-inflammatory congenital, vascular, neoplastic and metabolic differential considerations.

Paraneoplastic Arthritides: Insights to Pathogenesis, Diagnostic Approach, and Treatment

ABSTRACT

Paraneoplastic arthritides are a group of inflammatory rheumatic syndromes induced by an occult and manifest malignancy, characterized by a wide range of musculoskeletal signs and symptoms that masquerade other rheumatic diseases such as rheumatoid arthritis. Although the pathogenesis of paraneoplastic arthritides is unknown, immune-mediated mechanisms can induce a paraneoplastic syndrome, with a dominant feature the polyarthritis. Common entities of paraneoplastic arthritides include paraneoplastic polyarthritis, hypertrophic osteoarthropathy, remitting seronegative symmetrical synovitis with pitting edema, palmar fasciitis and polyarthritis, and polyarthritis and panniculitis associated with pancreatic carcinoma. The electronic databases PubMed and Scopus were scrutinized using the following terms: paraneoplastic arthritis, paraneoplastic polyarthritis, or paraneoplastic rheumatic diseases. Abstracts, full articles, and selected references were reviewed. The aim of the present narrative review article was to describe the clinical characteristics, diagnostic evaluation, and management of paraneoplastic arthritides, and highlight the challenges that health care providers may encounter, distinguishing those conditions from other autoimmune rheumatic disorders. Future studies are needed to give insight into the mechanisms associated with paraneoplastic arthritides, leading to the development of novel diagnostic biomarkers.

A unique presentation of destructive shoulder arthropathy in the chronic phase of chronic myeloid leukaemia

We present a previously unreported case of rapidly progressing, destructive shoulder arthropathy as an initial presentation of chronic phase chronic myeloid leukaemia. This patient initially presented to clinic for consideration of an arthroplasty for symptom relief; however, her loss to follow-up yielded a rapid progression of her symptoms. Bone marrow aspirate and targeted biopsy of the humeral head excluded blast cell crisis, in contrast to previously reported cases. She was treated conservatively with medical management of her underlying disease. Although leukaemic arthritis is a recognized phenomenon, chronic myeloid leukaemia is not known to cause bone destruction of this kind, particularly in the absence of blast crisis. Medical treatment with a tyrosine kinase inhibitor provided a dramatic improvement in our patient's pain, without the risk of attempted arthroplasty in unknown bone quality. We describe a unique presentation of severe bone destruction as a manifestation of chronic myeloid leukaemia in the absence of blast crisis. This should be considered as a rare differential diagnosis in joint arthropathy and may be appropriately managed initially with medical therapy, whereas future arthroplasty comprises uncharted territory in unknown bone quality.

[Synovial fluid cytodiagnosis]

Synovial fluid samples represent only a very small percentage of routine work in a cytology laboratory. However, its microscopic examination allows us to observe different types of cells, particles and structures that, due to their morphological characteristics, may provide relevant data for cytodiagnosis. We present certain aspects related to arthrocentesis, the relationship between the gross appearance of synovial fluid and certain pathological processes, as well as the different techniques for processing and staining the smears. Furthermore, we describe the main cytological findings in various pathological conditions of the synovial joints, such as infections (bacterial and fungal), non-infectious inflammatory type (osteoarthrosis, rheumatoid arthritis, connective tissue diseases) and tumoral, distinguishing between primary and metastatic, both solid and haematological neoplasms.

Hairy cell leukaemia variant with periarticular joint infiltration and excellent radiotherapy response

Hairy cell leukaemia (HCL) is rare, accounting for only 2% of leukaemias. An even more infrequent variant has been described, HCL-V. The clinicopathologic features of these two entities overlap significantly, although they differ in a number of aspects, including demographics and immunophenotype. In this report, we present the case of a man with HCL-V diagnosed 12 years previously, who is currently haematologically stable with an unusual complication of joint pain due to extensive bony expansion secondary to leukaemic infiltration, and atypical skeletal imaging. His painful joint disease responded dramatically to radiotherapy.

Diagnostic dilemma of paraneoplastic arthritis: case series

OBJECTIVES

Paraneoplastic arthritis (PA) may mimic rheumatic diseases. While presenting the demographic and laboratory features of the patients diagnosed with PA, this study also aims to provide possible appropriate tools to differentiate the PA cases from early rheumatoid arthritis (ERA).

METHODS

Sixty-five patients with PA (male/female: 43/22) from 15 different rheumatology clinics and 50 consecutive patients with ERA (male/female: 13/37) fulfilling the 2010 American College of Rheumatology (ACR) criteria for the diagnosis if the RA from Gaziantep Rheumatology Early Arthritis Trial (GREAT) as controls who were diagnosed at least 12 months before, were enrolled into study.

RESULTS

Mean ages of the patients with PA and ERA were 50.2 ± 15.3, and 42.7 ± 12.3, respectively, and the mean ages of the patients with PA were significantly higher than the ERA. Unlike the ERA patients, in our case series PA was predominantly observed among males. Oligoarthritis was significantly higher in solid tumors in contrast to ERA (P = 0.001). Polyarthritis and symmetric arthritis were significantly higher in the ERA group in contrast to all malignancies (P = 0.001). Rheumatoid factor (RF) and anticyclic citrullinated peptide antibody (anti-CCP) positivity were significantly higher in the ERA group (each P = 0.001). Lactic dehydrogenase levels of hematologic malignancies were significantly higher than other groups (each, P = 0.001).

CONCLUSIONS

ERA patients had more symmetric joint involvement than PA; laboratory markers could be also an alternative where there is high RF and anti-CCP positivity with antibody levels among the ERA patients. Finally, the demographic features can be used as differentiating factors; ERA was seen predominantly among females aged 40-59 years which refers to young adults.

Characteristics of 10 patients with paraneoplastic rheumatologic musculoskeletal manifestations

OBJECTIVES

To evaluate the possible correlation of malignant neoplasms and paraneoplastic rheumatologic syndromes.

METHODS

We studied a series of 10 patients with paraneoplastic rheumatological syndromes collected from our Division of Rheumatic Disease between 2006 and 2012.

RESULTS

Our series consisted of four males and six females, with a mean age of 65.5 years (range, 57-78 years). Of the 10 patients recruited, six had hematological malignancies and four had solid cancers. Malignancies were diagnosed after rheumatic symptoms were reported in all patients. Compared to solid tumors, hemopathy was diagnosed at a later time point (16.2 vs. 7.3 months). Extra-articular symptoms were associated with rheumatologic musculoskeletal manifestations in 100% of the patients. Polyarthritis was the main rheumatologic musculoskeletal manifestation (50% of the patients). The other manifestations were oligopolyarthritis and polymyalgia rheumatic-like symptoms (20% of the patients). Symmetric arthritis was present in 60% of the patients, and the remaining patients developed asymmetric arthritis. Musculoskeletal manifestations completely regressed in 66.7% of the patients after cancer therapy. When tumor relapse was observed, rheumatic symptoms did not recur in any of our patients (100%).

CONCLUSIONS

Rheumatic disorders with atypical clinical presentation in older patients, poor response to usual treatment and systemic features such as weight loss and clinical findings compatible with well-recognized paraneoplastic syndromes should alert clinicians to the possible coexistence of an occult malignancy. Especially in cases of paraneoplastic rheumatic/musculoskeletal manifestations associated with hemopathy, the primary disease is unlikely to have manifested yet, making the diagnosis difficult. Thus, caution is required.

Rheumatic manifestations of cancer

Taken together, the wide range of rheumatic and musculoskeletal conditions that can appear in association with cancer emphasizes that rheumatic disease is a major component of the spectrum of paraneoplastic manifestations. Although the pathogenetic mechanisms by which neoplasia causes these manifestations are only partially understood in select cases, it appears that many result from immune-mediated effects stimulated by tumor antigens of endocrine factors produced by tumors. The broad overlap in signs and symptoms of occult malignancy and systemic rheumatic disease, as well as the occurrence of distinct localized and systemic musculoskeletal and rheumatic syndromes in the presence of cancer, emphasizes the importance of considering and investigating the possibility of occult malignancy in the evaluation of patients with these symptoms. This is particularly important in older patients, those with atypical rheumatic disease, and those who do not respond appropriately to conventional immunosuppressive therapy.

[Gastrointestinal tumors. Clinical manifestations of paraneoplastic rheumatic symptoms]

Paraneoplastic syndromes, as syndromes associated with malignancy, can present unrelated to tumor invasion or metastases. They can occur with varying clinical appearance and are often indistinguishable from idiopathic rheumatic symptoms. Some musculoskeletal disorders are more associated with malignancies. The therapy of rheumatic syndromes can itself have an effect on the tumorigenic process. The clinical severity of paraneoplastic rheumatic symptoms can in many cases aid in the assessment of tumor activity and the response to therapy. While generally an extensive search for occult malignancies in every older rheumatoid patient in cases with no indications of malignancy is not advisable, knowledge of rheumatic symptoms associated with malignancies aids in the important early detection of tumors, while avoiding unnecessary examinations.

Rheumatologic manifestations of benign and malignant haematological disorders

Diseases of blood and lymphoreticular system can have multisystem manifestations. Rheumatologic involvement has been reported in association with many benign and malignant haematological disorders; these patients are equally likely to present to both clinical rheumatologists and haematologists. This review focuses on the well-described rheumatologic features, other occasionally reported rheumatologic manifestations and unusual musculoskeletal complications related to the treatment in patients with underlying haematological conditions. The aim of this review is to help increase the awareness of rheumatologic manifestations seen in the blood disorders and to highlight the potential diagnostic pitfalls.

Sacroiliitis as an initial presentation of acute lymphoblastic leukaemia

A 17-year-old male was admitted to the hospital because of fever, low back pain and knee pain which had started a couple of months ago. Pelvic CT-scan confirmed left sacroiliitis. Complete blood count revealed pancytopenia.A bone marrow biopsy and aspiration was performed under local anaesthesia. The pathologist reported Acute Lymphoblastic Leukaemia. The reported patient is the first case of acute lymphoblastic leukaemia, accompanied by sacroiliitis.

Acute Shoulder Monoarthritis in a Patient With Acute Myelomonocytic Leukemia With Novel Translocation t(5;13)

We present the case of a patient with acute myelomonocytic leukemia with trisomy 8 and novel translocation t(5;13). In addition to acute leukemia she had debilitating left shoulder arthritis due to granulocytic sarcoma formation in the joint space. Her shoulder pain did not improve during induction chemotherapy but she experienced rapid relief of symptoms with use of local radiation. Her leukemia was found to be primary refractory to chemotherapy and despite an attempt at salvage therapy she died 2 months after diagnosis.

Utility of synovial biopsy

Synovial biopsies, gained either by blind needle biopsy or minimally invasive arthroscopy, offer additional information in certain clinical situations where routine assessment has not permitted a certain diagnosis. In research settings, synovial histology and modern applications of molecular biology increase our insight into pathogenesis and enable responses to treatment with new therapeutic agents to be assessed directly at the pathophysiological level. This review focuses on the diagnostic usefulness of synovial biopsies in the light of actual developments.

Joint pain in AML: successful pain control with radiotherapy

We present a case supporting the use of radiation therapy for palliation of joint pain associated with acute myelogenous leukemia. Prior to radiation therapy to the affected joints, and despite standard pain management, this patient was entirely bedridden and in significant pain. Following radiation, she was able to participate in physiotherapy with minimal to no pain until her death several weeks later. A brief literature review of joint involvement in acute myelogenous leukemia is discussed.

Anaplastic large cell lymphoma presenting with symmetric polyarthritis in pregnancy

Anaplastic large-cell lymphoma (ALCL) is a rare T-cell lymphoma and typically is seen in children and young adults. Primary bone infiltration of ALCL is exceedingly rare. Herein we report ALCL of bone in a pregnant admitted with symmetric polyarthritis. Magnetic resonance imaging of the pelvis revealed soft tissue component of that destructive mass lesion on the right iliac crest after delivery. Excisional biopsy from the destructive mass showed anaplastic large cell lymphoma (CD 30 was positive and ALK negative). The patient was treated with combination chemotherapy consisting of cyclophosphamide, doxorubicin, vincristine and prednisolone (CHOP) every 4 weeks. After the third cycle of chemotherapy, a marked improvement of her arthritis and right iliac pain was noted.

An unusual presentation of multiple myeloma: a case report

Multiple myeloma can occasionally manifest with joint disease. We report the case of an individual with a progressive bilateral carpal syndrome and a symmetrical severe seronegative polyarthritis and joint swelling. Investigations revealed an erosive seronegative inflammatory arthritis in association with bilateral carpal tunnel syndrome, anaemia, hepatic impairment and nephrotic-range proteinuria. Synovial fluid cytology demonstrated plasmablasts and multinucleated cells with products of chondrolysis. The diagnosis of multiple myeloma (with secondary amyloidosis) was made on serum protein electrophoresis and bone marrow biopsy.The relationship between myeloma and joint disease is discussed, highlighted by the presence in this case of all three pathogenic features associated with arthritis in myeloma patients- an erosive arthritis, carpal tunnel syndrome and an invasive tumoural arthritis.

Radiologic investigation of rheumatic diseases

This article reviews the current use of the wide variety of imaging modalities now available, presenting the imaging features of common and important causes of acute and chronic rheumatic disorders including juvenile idiopathic arthritis, spondyloarthropathies/enthesitis-related arthritis, sepsis, autoimmune diseases, vasculitis, and osteoporosis.

Clonal identity between skin and synovial tissue in a case of mycosis fungoides with polyarthritis

Polyarthritis in the presence of a cutaneous T-cell lymphoma is a rare phenomenon. We describe a case of mycosis fungoides with development of a symmetric erosive polyarthritis of the small hand joints and feet, diagnosed as rheumatoid arthritis. An identical monoclonal T-cell population in the skin and in the synovium was detected by T-cell receptor gene rearrangement analysis, illustrating articular dissemination of lymphoma cells. Differentiating mycosis fungoides-associated arthritis from rheumatoid arthritis may have important implications for treatment. Based on this case, the relevant literature, and the newest disease concepts, pathogenic mechanisms and therapeutic options of mycosis fungoides-associated arthritis are discussed.

Diagnosis of malignancies in children with musculoskeletal complaints

CONTEXT

Musculoskeletal complaints may be associated with neoplasias as an initial manifestation of the disease. When these symptoms predominate at the onset of the disease, the differential diagnosis includes several rheumatic diseases.

OBJECTIVE

To assess the frequency, clinical features and types of cancer manifested in children presenting with musculoskeletal complaints over a seven-year period.

TYPE OF STUDY

Retrospective.

SETTING

Discipline of Allergy, Clinical Immunology and Rheumatology, Universidade Federal de São Paulo-Escola Paulista de Medicina.

METHODS

The medical records of patients with musculoskeletal complaints and final diagnosis of malignant disease were reviewed. The data collected were: age when symptoms initially presented, age at diagnosis, clinical features presented, laboratory findings, and the initial and final diagnoses.

RESULTS

A final diagnosis of cancer was found in nine out of 3,528 patients (0.25%) whose initial symptom was musculoskeletal pain. The mean time between disease onset and final diagnosis was five months. The most common features presented were pauciarticular arthritis or arthralgia involving the large joints. Juvenile rheumatoid arthritis was the most frequent initial diagnosis, in four out of nine patients. Anemia was the most frequent initial hematological change. Six out of eight patients had an increased erythrocyte sedimentation rate. The lactate dehydrogenase level was raised in five out of eight patients. The malignancies found included acute lymphocytic leukemia, acute myeloid leukemia, lymphoma, neuroblastoma and Ewing's sarcoma.

DISCUSSION

The frequency of neoplasia in patients with musculoskeletal pain resembled reports in the literature. Consumptive symptoms were not the warning signal in most of our patients. In subsidiary tests, progressive anemia was the most common finding, although the peripheral blood cell count may continue to be normal for weeks or months after symptom onset.

CONCLUSION

Malignancy always needs to be ruled out in cases of children with musculoskeletal complaints. Uncharacteristic clinical manifestations and nonspecific laboratory tests may cause difficulty in the final diagnosis, and rigorous investigation should be performed.

[Paraneoplastic rheumatism--musculoskeletal diseases as a first sign of hidden neoplasms]

Malignancy-associated musculoskeletal syndromes can present in a variety of ways which are not distinguishable from idiopathic rheumatic diseases. Furthermore, there are some rare, but typical syndromes with a high association with neoplasms. To perform a quick and exact diagnosis while avoiding useless invasive and expensive diagnostic procedures is a major challenge for the clinician. This article focuses on the clinical features of paraneoplastic musculoskeletal syndromes and theories about the underlying pathogenesis. We try to highlight those clinical and laboratory aspects which could be a clue to hidden malignancies. Paraneoplastic rheumatic syndromes are rare conditions, but timely recognition can save lives.

Cancer polyarthritis resembling rheumatoid arthritis as a first sign of hidden neoplasms. Report of two cases and review of the literature

Recent onset arthritis reminiscent of rheumatoid arthritis (RA) may be an early manifestation of an occult malignancy. In this report, we present two patients with cancer-associated polyarthritis. Both suffered from symmetric polyarthritis when initially visiting their physicians and did not achieve relief when treated with non-steroidal anti-rheumatic drugs (NSAIDs). In both patients, subsequent work-up led to the diagnosis of an underlying malignancy. One patient suffered from small cell lung cancer (SCLC), while the other was diagnosed with adenocarcinoma of the colon. In both, the arthritis spontaneously disappeared after successful treatment of the malignancy, i.e. chemotherapy and tumor resection, respectively. We discuss these cases in view of the existing literature, since awareness of the entity of cancer polyarthritis is necessary for its timely treatment and may potentially be life-saving.

Incidence of occult cancer in children presenting with musculoskeletal symptoms: a 10-year survey in a pediatric rheumatology unit

OBJECTIVES

To assess the frequency and types of cancer found in children presenting to our Unit with musculoskeletal symptoms over a 10-year period.

METHODS

The medical records of patients with musculoskeletal symptoms and a final diagnosis of cancer were reviewed. In each case age, gender, presenting symptoms, laboratory data, diagnostic procedures, provisional and final diagnoses, and time between clinical onset and correct diagnosis were reviewed.

RESULTS

An underlying neoplasia was found in 10 of 1,254 patients (<1%) complaining of musculoskeletal symptoms. The types of malignancies found included acute lymphocytic leukemia (ALL) (6 cases), lymphoma (2 cases), neuroblastoma (1 case), and Ewing's sarcoma (1 case). The mean time between disease onset and final diagnosis was 3.2 months. The most common presenting feature was monoarthritis, involving the larger joints such as the elbows, knees or ankles. Juvenile idiopathic arthritis (JIA) was the most frequent provisional diagnosis. In the preliminary hematologic evaluation, eight patients had an increased erythrocyte sedimentation rate (ESR) or C-reactive protein (CRP) value. White blood cell (WBC) count was normal in almost all children, with a normal differential count. Lactic dehydrogenase (LDH) was raised in all children. Bone marrow aspirates and lymph node or bone biopsies were necessary to reach the final diagnosis.

CONCLUSIONS

A malignancy should always be excluded in children with musculoskeletal symptoms, especially when the clinical pattern is not characteristic of a specific rheumatic disease. Routine laboratory tests may be misleading. The simultaneous presence of high LDH or alpha-hydroxybutyric dehydrogenase (alpha-HBDH) levels and raised ESR or CRP, even with normal blood cell counts, should lead to additional investigations.

RELEVANCE

All patients presenting with arthritis or other musculoskeletal symptoms should have a thorough clinical examination. Disproportionate pain levels and an atypical pattern of "arthritis," especially in the presence of systemic manifestations, suggest a possible underlying malignancy.

Osteoarticular disorders of haematological origin

Clinical abnormalities of the musculoskeletal system may be the first manifestation of sickle haemoglobinopathies, leukaemias, lymphomas and haemophilia. In addition to this, known patients with these diseases exhibit a variety of osteoarticular features. The painful crisis is the most common manifestation of sickle cell disorders, but avascular necrosis, osteomyelitis and various forms of arthritides are also common. In haematological malignancies, bone pain and arthritis may occur at any stage of the disease. The diagnosis must be confirmed by the presence of malignant cells on histological examination of various samples. Haemarthrosis is the main symptom of haemophilia. It needs early treatment to avoid damage to the joints. The availability of new safe coagulation factors has improved the prognosis of haemophilia.

Paraneoplastic rheumatic syndromes

Paraneoplastic rheumatic syndromes are challenging from both a clinical and research standpoint. Progress over the past decade has provided clarification of clinical syndromes. At the same time, our increasing ability to define and quantitate mediators of inflammation is shedding new light on pathogenesis. In turn, this understanding may answer questions regarding more common rheumatic diseases.

Successful treatment of lupus with fludarabine

We describe a 58-year old patient with chronic lymphocytic leukemia (CLL) who developed systemic lupus erythematosus (SLE) with severe joint involvement. Dilated myocardiopathy precluded the use of high corticoid doses and a 15 days of prednisone (15mg/d) had no effect on the polyarthritis. Therefore, fludarabine (25mg/m2) was administered for 5 d. One month after the first cycle, fever, muscle stiffness and polyarthritis resolved. A total of 6 cycles were administered. The evolution was complicated by herpes zoster infection and left pneumococcal pneumonia. At this time of writing (July 1999), the patient is symptom free but is profoundly lymphopenic.

Overexpanded B cell clone mediating leukemic arthritis by abundant secretion of interleukin-1beta: a case report

The role of cytokines in leukemic arthritis is unknown. The presentation of a patient with B cell chronic lymphocytic leukemia and destructive arthritis of the wrist joints prompted us to study the synovial cytokine pattern by immunohistologic analysis. In addition, rearranged V(H) and V(L) immunoglobulin genes were sequenced to assess B cell clonality. Heavy infiltrations of CD20+ cells with lambda light chain restriction were found in the synovial tissue. Sequencing demonstrated overexpansion of a single B cell clone (DP58/D/J(H)4b and IGLV3S2/Jlambda2-Jlambda3 for V(H) and V(L), respectively) in the peripheral blood. Identical V(H) and V(L) rearrangements were found in the synovial infiltrates. Somatic mutations were found in both the peripheral blood and the synovial clone. Immunohistologic study revealed the presence of abundant interleukin-1beta (IL-1beta) and, to a lesser degree, tumor necrosis factor beta (TNFbeta) (lymphotoxin). In contrast, TNFalpha, interferon-gamma, IL-4, IL-6, and IL-10 were rarely found in the synovial infiltrates. Therefore, IL-1beta secreted in great amounts by leukemic B cells appears to be the major cytokine that mediates joint destruction in leukemic arthritis.

Arthritis as a presenting feature of non-Hodgkin's lymphoma

Leukaemia can present with joint swelling in the absence of abnormal haematological findings. Arthritis as a presenting sign of lymphoma, however, is extremely rare. Three children with non-Hodgkin's lymphoma who had joint swelling at the onset of their disease are reported. Two cases showed histological features of anaplastic large cell lymphoma (Ki-1/CD30 positive), and one of angioimmunoblastic T cell lymphoma. In all patients the unusual presentation delayed correct diagnosis.

Facial heliotrope rash as the initial manifestation of acute myelomonocytic leukemia

The association of leukocytoclastic vasculitis or dermatomyositis with malignancies has been reported. We describe a patient who developed a skin rash, histologically compatible with dermatomyositis, which during the course of the disease switched to leukocytoclastic vasculitis, which was accompanied with peripheral blood pancytopenia in the absence of any specific pathological manifestation from the bone marrow three years prior to the diagnosis of acute myelomonocytic leukemia (AMML).