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Ito A, Osumi T, Fujimori K, Tomizawa D, Kato M, Tsuji S, Matsumoto K, Ishiguro A, Miyazaki O. Utility of emergent plain X-ray for childhood acute leukemia with bone pain. Pediatr Int 2022; 64:e14843. [PMID: 33998750 DOI: 10.1111/ped.14843] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/16/2020] [Revised: 04/08/2021] [Accepted: 05/12/2021] [Indexed: 11/30/2022]
Abstract
BACKGROUND We aimed to evaluate the utility of plain X-ray radiograph (PXR) findings in suggesting a diagnosis of acute leukemia in children presenting with bone pain in the emergency department (ED) of a children's hospital. METHODS Using our radiology reporting system and registered data for childhood acute leukemia, we collected data regarding patients who underwent musculoskeletal PXR examinations in the ED due to bone pain in their extremities, from March 1, 2002 to June 30, 2015. We retrospectively reviewed their PXR findings and clinical information from the electronic medical records. RESULTS A total of 1,331 patients underwent PXR examinations and in 12 PXR findings showed suspected acute leukemia. From the registered data we found 12 acute leukemia patients who underwent emergency extremity PXR. Ten patients were finally confirmed to have acute leukemia by bone marrow examinations. The most common finding was lucent metaphyseal bands, demonstrated in seven cases, whereas six patients did not show any abnormalities in their peripheral blood cell counts. Sensitivity and specificity values of PXR for acute leukemia diagnosis were 90.0% and 99.8%, respectively. Positive predictive value and negative predictive values were 75.0% and 99.9%, respectively. CONCLUSIONS Plain X-ray radiograph is a useful diagnostic tool to detect possible acute leukemia in patients presenting with bone pain, earlier than abnormalities of their peripheral blood cell counts. Our results implied the possibility of re-examining PXRs in acute leukemia more carefully, even when there are no abnormalities in blood cell counts.
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Affiliation(s)
- Ai Ito
- Children's Cancer Center National Center for Child Health and Development (NCCHD), Tokyo, Japan.,Center for Postgraduate Education and Training, NCCHD, Tokyo, Japan
| | - Tomoo Osumi
- Children's Cancer Center National Center for Child Health and Development (NCCHD), Tokyo, Japan
| | - Kentaro Fujimori
- Children's Cancer Center National Center for Child Health and Development (NCCHD), Tokyo, Japan
| | - Daisuke Tomizawa
- Children's Cancer Center National Center for Child Health and Development (NCCHD), Tokyo, Japan
| | - Motohiro Kato
- Children's Cancer Center National Center for Child Health and Development (NCCHD), Tokyo, Japan
| | - Satoshi Tsuji
- Division of Pediatric Emergency and Transport Services, NCCHD, Tokyo, Japan
| | - Kimikazu Matsumoto
- Children's Cancer Center National Center for Child Health and Development (NCCHD), Tokyo, Japan
| | - Akira Ishiguro
- Children's Cancer Center National Center for Child Health and Development (NCCHD), Tokyo, Japan.,Center for Postgraduate Education and Training, NCCHD, Tokyo, Japan
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Raj B K A, Singh KA, Shah H. Orthopedic manifestation as the presenting symptom of acute lymphoblastic leukemia. J Orthop 2020; 22:326-330. [PMID: 32675920 PMCID: PMC7340973 DOI: 10.1016/j.jor.2020.05.022] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/12/2020] [Revised: 04/24/2020] [Accepted: 05/31/2020] [Indexed: 11/23/2022] Open
Abstract
INTRODUCTION The diagnosis of Acute lymphoblastic leukemia (ALL) is delayed due to vague presentation and normal hematological investigations. OBJECTIVE The objectives were to identify the frequency of ALL cases presented to the orthopedic department and with normal hematological investigations. MATERIAL AND METHODS 250 consecutive ALL cases were retrospectively evaluated to identify cases with musculoskeletal manifestations, and laboratory investigations. RESULTS Twenty-two patients (4- vertebral compression fractures, 12- joint pain, 6- bone pain), presented primarily to the orthopedic department. Six patients had a normal peripheral smear. CONCLUSION The primary physician should maintain a high index of suspicion despite a normal peripheral smear.
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Affiliation(s)
- Amrath Raj B K
- Department of Orthopaedics, Kasturba Hospital, Kasturba Medical College, Manipal Academy of Higher Education, Manipal, India
| | | | - Hitesh Shah
- Department of Orthopaedics, Kasturba Hospital, Kasturba Medical College, Manipal Academy of Higher Education, Manipal, India
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Angsubhakorn N, Suvannasankha A. Acute lymphoblastic leukaemia with osteolytic bone lesions: diagnostic dilemma. BMJ Case Rep 2018; 2018:bcr-2018-225008. [PMID: 30100571 DOI: 10.1136/bcr-2018-225008] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
A previously healthy 37-year-old man presented with a 10-month history of intractable back pain. On examination, there was tenderness to palpation along lower thoracic and lumbar spine. Complete blood count showed mild anaemia but was otherwise unremarkable. Imaging studies revealed compression deformities with multiple osteolytic lesions involving multiple levels of the thoracic and lumbar spine. Bone marrow aspiration and biopsy were performed and demonstrated blast cells involving 80% of the bone marrow cellularity. Findings on flow cytometry were consistent with B-lymphoblastic leukaemia. He was subsequently started on hyper-CVAD (fractionated cyclophosphamide, vincristine, Adriamycin and dexamethasone) induction chemotherapy.
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Affiliation(s)
- Natthapon Angsubhakorn
- Department of Medicine, University of Minnesota Medical School Twin Cities, Minneapolis, Minnesota, USA
| | - Attaya Suvannasankha
- Division of Hematology/Oncology, Department of Medicine, Indiana University School of Medicine, Indianapolis, Indiana, USA
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Lázaro Carreño M, Fraile Currius R, García Clemente A. Non-traumatic limping in Paediatric Emergencies: Epidemiology, evaluation and results. Rev Esp Cir Ortop Traumatol (Engl Ed) 2018. [DOI: 10.1016/j.recote.2017.12.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
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Lázaro Carreño MI, Fraile Currius R, García Clemente A. Non-traumatic limping in Paediatric Emergencies: Epidemiology, evaluation and results. Rev Esp Cir Ortop Traumatol (Engl Ed) 2017; 62:127-133. [PMID: 29138043 DOI: 10.1016/j.recot.2017.10.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/08/2017] [Revised: 09/21/2017] [Accepted: 10/04/2017] [Indexed: 10/18/2022] Open
Abstract
INTRODUCTION Non-traumatic limping is a common reason for consultation in paediatric emergencies. Although transient synovitis of the hip (TS) is the most frequent diagnosis, there are cases of limping secondary to serious pathologies. The aim of this review is to describe the variables related to non-traumatic limp that come to the paediatric emergency department to establish the best management protocol, making the most of resources and speeding up emergency care. MATERIAL AND METHOD A prospective study was conducted, selecting all children less than 15 years old who consulted aspaediatric emergencies for non-traumatic limping during the 2014. Clinical variables, complementary examinations and diagnoses were collected in the emergency room consultation and 6 months after the consultation RESULTS: During 2014, 146 patients (0.69% of the emergencies) were included in the non-traumatic limping study. Four cases of severe limping were diagnosed: 2 leukaemias, 1 septic arthritis and 1 acetabular bone tumour. The most frequent diagnosis was TS (53.16%). At 6 months, 135 children (92.4%) had resolved lameness. The diagnosis was changed in 9 children (6.1%). Children with TS had fewer days of evolution, and 77% were between 3 and 10 years old. Children with a final diagnosis of severe pathology had a limp for longer, fever and did not weight bear on ambulation. CONCLUSIONS In limping of probable hip origin, at the ages of between 3 and 10, without fever or systemic symptoms and of less than one week's onset, it is possible to make a clinical diagnosis of TS limiting the use of complementary examinations.
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Affiliation(s)
- M I Lázaro Carreño
- Servicio de Pediatría, Sección Urgencias Pediátricas, Hospital Clínico Universitario de Valencia, Valencia, España.
| | - R Fraile Currius
- Servicio de Pediatría, Sección Urgencias Pediátricas, Hospital Clínico Universitario de Valencia, Valencia, España
| | - A García Clemente
- Servicio de Pediatría, Sección Urgencias Pediátricas, Hospital Clínico Universitario de Valencia, Valencia, España
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Ray P, Girach J, Sanghrajka AP. Ewing's sarcoma of the pelvis: an unusual, but not to be missed, cause of an irritable hip. BMJ Case Rep 2016; 2016:bcr-2015-213782. [PMID: 26795741 DOI: 10.1136/bcr-2015-213782] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022] Open
Abstract
A 15-year-old girl presented with a 2-month history of non-specific right hip pain associated with pain in the back, right flank and foot. Her symptoms deteriorated, interfering with weight-bearing. Following admission, she was found to be febrile with a flexion deformity of her right-hip, and tenderness over the iliac crest and posterior pelvis. A markedly elevated C reactive protein and erythrocyte sedimentation rate, with an ultrasound-proven scan effusion within the right hip were all suggestive of septic arthritis. However, full blood count demonstrated a significant anaemia, which together with the tenderness around the pelvis was not in keeping with this diagnosis. Surgical washout was therefore delayed to obtain a MRI scan of the pelvis. The scan revealed a 5×5×3 cm necrotic soft tissue mass within the gluteal muscles, arising from the right ilium, which biopsy confirmed to be a Ewing's sarcoma.
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Affiliation(s)
- Partha Ray
- Department of Trauma and Orthopaedic Surgery, Norfolk and Norwich University Hospital, Norwich, UK Department of Surgery, James Paget University Hospital, Gorleston-on-Sea, UK
| | - Julekha Girach
- Norwich Medical School, University of East Anglia, Norwich, UK
| | - Anish Pradip Sanghrajka
- Department of Trauma and Orthopaedic Surgery, Norfolk and Norwich University Hospital, Norwich, UK
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Abstract
Limping in children is a common complaint at pediatric, pediatric orthopaedic offices and in emergency rooms. There are several causes for this condition, and identifying them is a challenge. The older the patient, the better the anamnesis and more detailed the physical examination will be, enabling an easier medical assessment for searching the source of the disorder. In order to make the approach easier, three age groups can and should be considered. Among infants (1 to 3 years old), diagnosis will most likely be: transitory synovitis, septic arthritis, neurological disorders (mild brain palsy (BP) and muscular dystrophy), congenital hip dislocation (CHD), varus thigh, juvenile rheumatoid arthritis (JRA) and neoplasias (osteoid osteoma, leukemia); in the scholar age group, between 4 and 10 years old, in addition to the diagnoses above, Legg-Calvé-Perthes disease, discoid meniscus, inferior limbs discrepancy and unspecific muscular pain; in adolescents (11 to 15 years old): slipped capital femoral epiphysis, congenital hip dislocation, chondrolysis, overuse syndromes, dissecans osteochondritis, and tarsal coalition. The purpose of this study is to provide an update on how to approach pediatric patients presenting with limping, and to discuss its potential causes.
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Affiliation(s)
- Cláudio Santili
- Department of Orthopedics and Traumatology, Faculdade de Ciências Médicas, Santa Casa de Sao Paulo; Assistant Physician, Pediatric Orthopedics and Traumatology Group, Irmandade da Santa Casa de Misericórdia de Sao Paulo, Sao Paulo, Brazil
- Correspondence: Dr. Cláudio Santili, Departamento de Ortopedia e Traumatologia da Santa Casa de São Paulo-Grupo de Ortopedia e Traumatologia Pediátrica, Rua Cesário Mota Junior, 112-01277-900-São Paulo, SPCorrespondence: Dr. Cláudio SantiliDepartamento de Ortopedia e Traumatologia da Santa Casa de São Paulo-Grupo de Ortopedia e Traumatologia PediátricaRua Cesário Mota Junior112-01277-900-São Paulo, SP.
| | - Wilson Lino Júnior
- Pediatric Orthopedics and Traumatology Group, Irmandade da Santa Casa de Misericórdia de Sao Paulo, Sao Paulo, Brazil
| | - Ellen de Oliveira Goiano
- Interning Physician, Pediatric Orthopedics and Traumatology Group, Irmandade da Santa Casa de Misericórdia de Sao Paulo, Sao Paulo, Brazil
| | - Romero Antunes Barreto Lins
- Resident (R3) Physician, Department of Orthopedics and Traumatology, Faculdade de Ciências Médicas, Santa Casa de Sao Paulo, Sao Paulo, Brazil
| | - Gilberto Waisberg
- Pediatric Orthopedics and Traumatology Group, Irmandade da Santa Casa de Misericórdia de Sao Paulo, Sao Paulo, Brazil
| | - Susana dos Reis Braga
- Master in Orthopedics, Faculdade de Ciências Médicas, Santa Casa de Sao Paulo; Physician, Pediatric Orthopedics and Traumatology Group, Irmandade da Santa Casa de Misericórdia de São Paulo, São Paulo, Brazil
| | - Miguel Akkari
- Head, Pediatric Orthopedics and Traumatology Group, Irmandade da Santa Casa de Misericórdia de São Paulo, São Paulo, Brazil
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Abstract
Joint pains are a common reason for children to present to primary care. The differential diagnosis is large including some diseases that do not primarily affect the musculoskeletal system. Although the cause for many patients will be benign and self-resolving, in rare cases the diagnosis is associated with long-term morbidity and mortality if not detected early and appropriately treated. These include primary and secondary malignancies, septic arthritis, osteomyelitis, inflammatory arthritis, slipped upper femoral epiphysis (SUFE) and non-accidental injury. We highlight the importance of a thorough history and directed yet comprehensive examination. A diagnostic algorithm is provided to direct primary care physicians' clinical assessment and investigation with the evidence base where available. In many cases, tests are not required, but if there is suspicion of malignancy, infection or inflammatory conditions, laboratory tests including full blood count, blood film, erythrocyte sedimentation rate, C-reactive protein and lactate dehydrogenase help to support or exclude the diagnosis. Autoimmune tests, such as antinuclear antibodies and rheumatoid factor, have no diagnostic role in juvenile idiopathic arthritis; therefore, we advise against any form of 'rheumatological/autoimmune disease screen' in primary care. Imaging does have a place in the diagnosis of joint pains in children, with plain radiographs being most appropriate for suspected fractures and SUFE, whilst ultrasound is better for the detection of inflammatory or infective effusions. The appropriate referral of children to paediatric rheumatologists, oncologists, orthopaedic surgeons and the emergency department are discussed.
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Affiliation(s)
- E S Sen
- Department of Paediatric Rheumatology, Bristol Royal Hospital for Children, Bristol, UK; School of Clinical Sciences, University of Bristol, Bristol, UK
| | - S L N Clarke
- Department of Paediatric Rheumatology, Bristol Royal Hospital for Children, Bristol, UK; School of Clinical Sciences, University of Bristol, Bristol, UK
| | - A V Ramanan
- Department of Paediatric Rheumatology, Bristol Royal Hospital for Children, Bristol, UK.
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Abstract
A 10-year-old child presented with a limp for 9 months. The child was keeping his right knee extended and foot in the equinus position. The child had been investigated by numerous laboratory investigations and imaging procedures during the initial 9 months, but no organic cause was found. Without any conclusive diagnosis, the child was being managed by physical therapy. During examination in our clinic, the variable contraction of the quadriceps muscle raised the possibility of a psychiatric disorder. A psychiatrist's opinion was sought and the child was found to have dissociative motor disorder. His conflict was identified and treated by cognitive behavioral therapy. The child walked normally after 1 week. A psychogenic limp is often not suspected by the orthopedic surgeon in the evaluation of a limp. The involvement of a psychiatrist in this evaluation may be helpful to identify the condition easily and even at the first instance.
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Affiliation(s)
- Sujit K Tripathy
- Departments of aOrthopedics bPsychiatry, AIIMS cDepartment of Psychiatry, KIMS, Bhubaneswar, Odisha, India
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Sakata H, Nakao A, Matsuda K, Yoshie N, Yamada T, Osako T, Iwano M, Kotani J. Acute leukemia presenting as bone pain with normal white blood cell count. Acute Med Surg 2014; 1:249. [PMID: 29930859 DOI: 10.1002/ams2.46] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022] Open
Affiliation(s)
- Hiroyuki Sakata
- Department of Emergency, Disaster and Critical Care Medicine Hyogo College of Medicine Hyogo Japan
| | - Atsunori Nakao
- Department of Emergency, Disaster and Critical Care Medicine Hyogo College of Medicine Hyogo Japan
| | - Kennichi Matsuda
- Department of Emergency, Disaster and Critical Care Medicine Hyogo College of Medicine Hyogo Japan
| | - Norichika Yoshie
- Department of Emergency, Disaster and Critical Care Medicine Hyogo College of Medicine Hyogo Japan
| | - Taihei Yamada
- Department of Emergency, Disaster and Critical Care Medicine Hyogo College of Medicine Hyogo Japan
| | - Takaaki Osako
- Department of Emergency, Disaster and Critical Care Medicine Hyogo College of Medicine Hyogo Japan
| | - Mika Iwano
- Department of Emergency, Disaster and Critical Care Medicine Hyogo College of Medicine Hyogo Japan
| | - Joji Kotani
- Department of Emergency, Disaster and Critical Care Medicine Hyogo College of Medicine Hyogo Japan
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Baunin C, Vial J, Labarre D, Domenech-Fontenel C, Railhac J, Sans N. [The chronically limping child]. JOURNAL DE RADIOLOGIE 2011; 92:506-514. [PMID: 21704246 DOI: 10.1016/j.jradio.2011.04.002] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/11/2011] [Accepted: 04/11/2011] [Indexed: 05/31/2023]
Abstract
Chronic limping in children usually indicates the presence of an underlying organic lesion. Clinical evaluation establishes the site and type of limping. It may suggest a neurological or mechanical lesion or locoregional etiology at the level of the hip or pelvis. Plain radiographs and ultrasound are firstline imaging techniques. The diagnosis may be delayed either due to ignorance of age-specific entities or false positive or negative results on plain films and ultrasound. MRI now plays a major role for diagnosis. Multiple potential underlying etiologies including trauma, infections, arthritides or tumors are best evaluated with MRI. The MRI examination should not be limited only to the hip joint.
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Affiliation(s)
- C Baunin
- Imagerie Pédiatrique, Hôpital des Enfants, 330 Avenue de Grande-Bretagne, 31059 Toulouse cedex 9, France.
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Gupta D, Singh S, Suri D, Ahluwalia J, Das R, Varma N. Arthritic presentation of acute leukemia in children: experience from a tertiary care centre in North India. Rheumatol Int 2009; 30:767-70. [PMID: 19633857 DOI: 10.1007/s00296-009-1064-7] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2008] [Accepted: 07/12/2009] [Indexed: 11/29/2022]
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Pediatric leukemia revealed by a limping episode: a report of four cases. Orthop Traumatol Surg Res 2009; 95:77-81. [PMID: 19251241 DOI: 10.1016/j.otsr.2008.09.004] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/28/2008] [Accepted: 09/30/2008] [Indexed: 02/02/2023]
Abstract
Acute limping in children is a common reason for consultation in pediatric emergency units. Acute leukemia is a rarely encountered disease in the orthopedic surgeon's activity. In addition, its clinical presentation is not typical and therefore is a source of possible diagnostic delay. For such reasons, there is a definite risk of undiagnosing the actual etiology of the limping episode. We report our experience with four cases of children initially seen in the pediatric emergency department for limping, as their revealing presentation of acute leukemia. The limb pain was highly variable. The radiographic work-up was always normal. Peripheral blood abnormalities were initially absent in one case and blastic cells were absent in two cases. The physician in charge should remember that paraclinical work-up normal results do not exclude a diagnosis of acute leukemia, that any drop in hematopoietic cell counts should call for a myelogram and that paraclinical exams, including the hemogram, should be repeated until a diagnosis and improvement or confirmed cure is achieved over time.
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Bekmezian A, Gomperts B. Case 1: A limping child…with abdominal pain. Paediatr Child Health 2008; 13:775-7. [DOI: 10.1093/pch/13.9.775] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/18/2008] [Indexed: 11/13/2022] Open
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Serra-Bonett N, Guzmán Y, Rodríguez E, Millán A, Rodríguez MA. [Acute leukemia in children erroneously diagnosed as idiopathic juvenile arthritis]. ACTA ACUST UNITED AC 2008; 4:70-3. [PMID: 21794501 DOI: 10.1016/s1699-258x(08)71803-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2006] [Accepted: 01/08/2007] [Indexed: 11/29/2022]
Abstract
We here present 3 Venezuelan children with acute leukemia, initially diagnosed as idiopathic juvenile arthritis because of the occurrence of pain and joint swelling at the onset of disease. Joint pain was aggravated at night and the arthritis showed a migratory pattern, mainly affecting large joints in an asymmetrical fashion. One patient presented with persistent unilateral sacroiliac pain leading to a wrong diagnosis of spondyloarthritis. The elevation of acute phase reactants, disproportionate to the extent of joint disease, and marked elevation of serum lactate dehydrogenase, as well as characteristicradiological changes allowed the correct diagnosis in all cases. This combination of clinical manifestations, clinical laboratory findings, and joint and bone imaging should prompt the clinician to an early diagnosis of acute leukemia in children with arthritis.
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Affiliation(s)
- Natalí Serra-Bonett
- Servicio de Reumatología. Centro Nacional de Enfermedades Reumáticas. Caracas. Venezuela
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Robazzi TCMV, Barreto JHS, Silva LR, Santiago MB, Mendonça N. Osteoarticular manifestations as initial presentation of acute leukemias in children and adolescents in Bahia, Brazil. J Pediatr Hematol Oncol 2007; 29:622-6. [PMID: 17805037 DOI: 10.1097/mph.0b013e3181468c55] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE This study was to determine the prevalence and characteristics of the osteoarticular manifestations on initial clinical presentation of acute leukemias (ALs) on childhood in the state of Bahia, Brazil. MATERIALS AND METHODS This retrospective study assessed the medical records of 406 patients with AL from January 1995 to December 2004. RESULTS Acute lymphocytic leukemia (ALL) was diagnosed in 313 (77.1%) patients and acute myeloid leukemia (AML), in 93 (22.9%) patients, including 241 males (59.4%) and 165 females (40.6%). Age ranged from 9 months to 15 years (average: 6.18 y). The most common presenting features were fever (18.5%), musculoskeletal diffuse tenderness (15.0%), pallor (11.4%), and leg tenderness (5.7%). Prior referral to our center, the most frequent initial diagnosis was anemia (15.8%), leukemia (15.0%), amygdalitis (3.7%), and rheumatic fever (2.7%). Osteoarticular manifestations were found on 54.7% of the patients with AL, with a higher frequency among patients between 1 and 9 years of age (58.7%, P=0.0007). The presence of joint tenderness (16.2% in ALLx5.4% in AML), arthritis (26.6% in ALLx9.7 in AML), bone tenderness (26.1% in ALLx16.1% in AML), limb tenderness (49.5% in ALLx25.8% in AML), and antalgic gait (32.8% in ALLx9.7% in AML) had higher prevalence on ALL. The large joints, chiefly the knees (10.6%), ankles (9.4%), elbows (4.4%), and shoulders (3.6%) were more often affected. CONCLUSIONS AL should be considered on the differential diagnosis of osteoarticular symptoms of unknown etiology in children.
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Affiliation(s)
- Teresa Cristina Martins Vicente Robazzi
- Pediatric Rheumatology Unit at Hospital São Rafael, Fundação Monte Tabor, and Pediatric Gastroenterology and Hepatology Service of Federal University of Bahia, Bahian Medical and Public Health School, Salvador, Bahia, Brazil.
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Acute lymphoblastic leukemia in children: correlation of musculoskeletal manifestations and immunophenotypes. J Child Orthop 2007; 1:63-8. [PMID: 19308508 PMCID: PMC2656700 DOI: 10.1007/s11832-007-0013-9] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/14/2007] [Accepted: 01/18/2007] [Indexed: 02/03/2023] Open
Abstract
PURPOSE Studies on musculoskeletal manifestations (MSM) of childhood acute lymphoblastic leukemia (ALL) have yielded variable findings with regard to their clinical impact. We investigated the significance for differential diagnosis, treatment and outcome of musculoskeletal complaints as presenting symptoms of ALL, and their correlation with leukemia immunophenotypes, for which data is lacking. METHODS Data on 783 children in the national study for childhood ALL between 1984 and 2003 were reviewed retrospectively. Statistical analysis examined possible relationships between MSM at the time of diagnosis and demographic and clinical data, biological features of leukemia (peripheral blood counts, immunophenotype and main cytogenetic aberration), response to initial prednisone treatment, and outcome. RESULTS Of 765 children with data on orthopaedic complaints, 240 presented with MSM (31.4%). Among these children, B cell precursor (BCP) was much more common (209/576, 36.3%) than T cell ALL (25/176, 14.2%). Patients with MSM had lower white blood cell counts (WBC) (median of 9 vs. 20 x 10(9)/L, P < 0.001) and percentage of blast cells in the peripheral blood at diagnosis compared to those without (median of 27 vs. 53%, P < 0.001). Hepatomegaly and splenomegaly were less common in MSM group (67 vs. 53% <3 cm, P < 0.001, and 63 vs. 50% <3 cm, P < 0.001, respectively). Poor response to initial treatment with prednisone was recorded in 7.1% of patients with MSM versus 11.5% of those without (P = 0.086). The analysis revealed no independent effect of MSM on event-free survival (EFS), after correcting for differences in EFS related to immunophenotype or initial WBC. CONCLUSIONS MSM occur mostly in children with BCP ALL who present with less involvement of extramedullary organs, low peripheral blood blasts and white blood cells counts. These findings highlight the importance of including ALL in the differential diagnosis of MSM even in the presence of an apparently normal peripheral blood count. Our study also suggests that MSM are caused by leukemic cells with enhanced biological propensity to remain relatively confined within the intramedullary bone-marrow space.
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Abstract
Evaluation of children who have hip pain can be a diagnostic challenge. This article reviews pertinent history taking, physical examination, laboratory testing, and imaging studies that assist in reaching a correct diagnosis. It also reviews the diagnostic categories that are important in formulating a differential diagnosis to frame clinical decision making.
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Affiliation(s)
- Steven L Frick
- Carolinas Medical Center, P.O. Box 32861, Charlotte, NC 28232, USA.
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Abstract
A limp suggests an underlying pathology causing the abnormal gait pattern. There is a long list of possible causes. The challenge for the physician is to identify the cause and act accordingly. The purpose of this article is to instruct on the assessment of a child with a limp.
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Affiliation(s)
- Paul Gibbons
- Department of Orthopaedic Surgery, The Children’s Hospital at Westmead, Sydney, Australia,
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Kobayashi D, Satsuma S, Kamegaya M, Haga N, Shimomura S, Fujii T, Yoshiya S. Musculoskeletal conditions of acute leukemia and malignant lymphoma in children. J Pediatr Orthop B 2005; 14:156-61. [PMID: 15812284 DOI: 10.1097/01202412-200505000-00003] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/10/2023]
Abstract
We retrospectively reviewed 16 patients who presented to hospitals with orthopaedic complaints. Twelve patients experienced initial symptoms in the extremities and four patients had back pain. The leukocyte count was elevated in one patient, decreased in two patients, and normal in 13 patients. On radiographic examination, osteopenia was observed in 10 patients, osteolytic lesions were observed in five, and pathologic fractures were observed in five. Because the initial presentation of patients with leukemia often involves the musculoskeletal system, orthopaedists need to recognize the symptoms of this disease to avoid misdiagnosis and to expedite the initiation of appropriate potentially lifesaving treatment.
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Affiliation(s)
- Daisuke Kobayashi
- Department of Orthopaedic Surgery, Kobe Children's Hospital, Kobe, Japan.
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23
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Gonçalves M, Terreri MTRA, Barbosa CMPL, Len CA, Lee L, Hilário MOE. Diagnosis of malignancies in children with musculoskeletal complaints. SAO PAULO MED J 2005; 123:21-3. [PMID: 15821811 DOI: 10.1590/s1516-31802005000100005] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
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.
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Affiliation(s)
- Marcela Gonçalves
- Department of Pediatrics, Universidade Federal de São Paulo, Escola Paulista de Medicina, São Paulo, Brazil
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24
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Dorronsoro Martín I, Merino Muñoz R, Sastre-Urguellés A, García-Miguel García-Rosado P, García-Consuegra Molina J. [Malignant disease presenting as rheumatic manifestations]. An Pediatr (Barc) 2004; 61:393-7. [PMID: 15530317 DOI: 10.1016/s1695-4033(04)78412-x] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022] Open
Abstract
BACKGROUND Musculoskeletal pain is a frequent complaint in pediatrics in both tertiary and primary care. Although musculoskeletal symptoms are not usually related to severe disease, they can represent the first manifestation of an occult malignancy. OBJECTIVE To describe the clinical manifestations and complementary findings of the patients referred to a pediatric rheumatology unit with a final diagnosis of malignancy. MATERIAL AND METHODS We performed a retrospective review of all the children referred to a pediatric rheumatology unit between 1992 and 2002 whose final diagnosis was cancer. RESULTS Of 3,982 patients referred, 10 had a final diagnosis of neoplasia (0.25 %). Six children were diagnosed with acute lymphoblastic leukemia, two with Langerhans' cell histiocytosis, one with Ewing's sarcoma, and one with metastases from retinoblastoma. The most frequent symptoms were arthralgias, limp, or back pain. Laboratory studies revealed anemia and a significant increase in sedimentation rate and lactate dehydrogenase values. Imaging studies contributed significantly to the diagnosis. The diagnosis was confirmed by bone marrow aspirate in children with leukemia and by bone biopsy in those with bone tumors. CONCLUSIONS Malignancies should be considered in the differential diagnosis of children with musculoskeletal pain, especially in the presence of organomegalies or abnormal laboratory or imaging studies.
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Affiliation(s)
- I Dorronsoro Martín
- Unidad de Reumatología Pediátrica, Hospital Universitario La Paz, Madrid, Spain.
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25
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Abstract
A limp is a common reason for a child to present to the orthopaedist. Because of the long list of potential diagnoses, some of which demand urgent treatment, an organized approach to evaluation is required. With an understanding of normal and abnormal gait, a directed history and physical examination, and the development of a differential diagnosis based on the type of limp, the patient's age, and the anatomic site that is most likely affected, the orthopaedist can take a selective approach to diagnostic testing. Laboratory tests are indicated when infection, inflammatory arthritis, or a malignant condition is in the differential diagnosis. The C-reactive protein assay is the most sensitive early test for musculoskeletal infections; an abnormal value rapidly returns to normal with effective treatment. Imaging should begin with plain radiography. Ultrasonography is particularly valuable in assessing the irritable hip and guiding aspiration, if necessary.
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Affiliation(s)
- J M Flynn
- University of Pennsylvania School of Medicine, Philadelphia, PA, USA
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26
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Trapani S, Grisolia F, Simonini G, Calabri GB, Falcini F. Incidence of occult cancer in children presenting with musculoskeletal symptoms: a 10-year survey in a pediatric rheumatology unit. Semin Arthritis Rheum 2000; 29:348-59. [PMID: 10924020 DOI: 10.1053/sarh.2000.5752] [Citation(s) in RCA: 72] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
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.
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Affiliation(s)
- S Trapani
- Department of Pediatrics, A. Meyer Hospital, University of Florence, Italy
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27
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Abstract
BACKGROUND The time between the initial symptoms of osteosarcoma and Ewing sarcoma and the correct diagnosis and treatment is long. Over the last two decades, the prognosis for patients with these diseases has dramatically improved due to a new chemotherapy regimen. As a consequence, a limb-sparing operation has become an alternative to amputation. The aim of this study was to establish the initial symptoms and physical signs of osteosarcoma and Ewing sarcoma from the records of the first medical visit and to identify early characteristics of the diseases to shorten the delay to diagnosis. METHODS A group of patients with osteosarcoma or Ewing sarcoma was identified from the Swedish Cancer Register of patients thirty years old and younger. Records from the first medical visit due to symptoms related to the bone tumor were obtained for 102 patients with osteosarcoma and forty-seven patients with Ewing sarcoma. RESULTS Pain related to strain was reported by eighty-seven (85 percent) of the patients with osteosarcoma and thirty (64 percent) of those with Ewing sarcoma, but only twenty-one (21 percent) of the patients with osteosarcoma and nine (19 percent) of those with Ewing sarcoma reported pain at night. Forty-eight (47 percent) of the patients with osteosarcoma and twelve (26 percent) of those with Ewing sarcoma related the onset of symptoms to minor trauma occurring around the same time. A palpable mass was noted in forty (39 percent) of the patients with osteosarcoma and sixteen (34 percent) of those with Ewing sarcoma at the first visit, and in most cases the tumor diagnosis was suspected. There was a broad spectrum of misdiagnoses; the most common was tendinitis, which was the initial diagnosis in thirty-two (31 percent) of the patients with osteosarcoma and ten (21 percent) of those with Ewing sarcoma. The doctor's delay (the period from the first medical visit due to the symptoms to the correct diagnosis) was longer for Ewing sarcoma than for osteosarcoma (nineteen weeks and nine weeks, respectively; p < 0.0001). CONCLUSIONS An initial symptom of both osteosarcoma and Ewing sarcoma was pain, which was intermittent and often related to strain but not frequently felt at night. A history of trauma was common, but the clinical course often diverged from what was expected from trauma. The clinical course of osteosarcoma and particularly of Ewing sarcoma was not steadily progressive but intermittent, which often misled the doctor into believing that the condition was temporary. The most important clinical feature was a palpable mass, which was noted in more than one-third of the patients at the first visit. This finding emphasizes that a thorough physical examination is absolutely necessary.
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Affiliation(s)
- B Widhe
- Department of Orthopedics, Huddinge University Hospital, Sweden.
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