Case of the MonthDifferential diagnosis of paediatric bone pain: Acute lymphoblastic leukemia
Introduction
Acute lymphoblastic leukemia (ALL) is the commonest malignancy in childhood. While most patients with ALL present with pallor or bleeding signs, some present with localized or diffuse bone pains and these patients often have relatively normal full blood counts (FBC) and a lower incidence of organomegaly [1], [2]. It is presumed that the bone pain is caused by leukemic cells infiltrating the intramedullary bone marrow space [3]. This form of presentation can lead to delays in the diagnosis of ALL.
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Case report
In November 2005, an 11-year-old boy was admitted to hospital with a history of left knee pain and limp of 3 months duration. He had headaches with recent onset of night sweats and a weight loss of 5 kg. On examination he had no pallor or lymphadenopathy, no organomegaly or rash. Plain X-ray revealed a subtle lucency within the left ilium. A bone scan showed multifocal increased uptake in the left femur and patella with possible involvement of the left femoral head and ischium. MRI
Discussion
Our patient initially presented with severe bone pain and limp but no organomegaly and a normal FBC. There are reports in the literature of such patients with the associated ‘delays’ in diagnosis [1]. Due to the high suspicion of ALL at initial presentation, a BM aspiration was performed but did not demonstrate any blast cells. The retrospective demonstration of low-level MRD in the original BM preparation raises the issue of ‘patchy’ changes in the BM. Early reports from the 1970s seem to
Acknowledgement
The authors declare no financial support or conflict of interest.
Contributions. All authors contributed to either collecting and analysing clinical data or to laboratory analyses. All authors contributed to the writing and revision of the manuscript.
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