Bone pain as an initial symptom of childhood acute lymphoblastic leukemia: association with nearly normal hematologic indexes

Survival rates of children with acute lymphoblastic leukemia presenting to a pediatric rheumatologist in the United States

BACKGROUND

Approximately 30% of pediatric acute lymphoblastic leukemia patients present with musculoskeletal symptoms and are often referred first to a pediatric rheumatologist. We examined the survival and causes of death of these patients presenting to a pediatric rheumatologist and compared the rates with that reported in the hematology-oncology literature.

PROCEDURE

We used the Pediatric Rheumatology Disease Registry, including 49,023 patients from 62 centers, newly diagnosed between 1992 and 2001. Identifiers were matched with the Social Security Death Index censored for March 2005. Deaths were confirmed by death certificates, referring physicians, and medical records. Causes of death were derived by chart review or from the death certificate.

RESULTS

There were 7 deaths of 89 patients (7.9%, 95% confidence interval: 3.9%-15.4%) with acute lymphoblastic leukemia with a 5-year survival rate of 95.5% (88.3 to 98.3) and 10-year survival rate of 89.8% (79.0% to 95.2%). The causes of death were sepsis (bacterial and/or fungal) in 4 (57%) patients, the disease in 2 (29%) and post bone-marrow transplantation in 1 (14%).

CONCLUSION

The overall survival of patients with acute lymphoblastic leukemia seen first by pediatric rheumatologists is higher than the range reported in the pediatric oncology literature for the same period of diagnosis.

Pain in malignant hematology

Pain is frequently experienced by patients with hematological malignancies, although it often receives little attention. Different underlying causes and mechanisms may sustain several pain syndromes in hematological malignant patients. Pain may be due to disease itself, to disease-related complications, to iatrogenic causes or may be associated with unrelated medical conditions. The management of pain in this setting requires a multidisciplinary approach, integrating analgesics and causal interventions. An accurate diagnostic assessment and the identification of the underlying causes and pathogenetic mechanisms may dictate the treatment approach. For most pain patients, the WHO's three-step analgesic scale for cancer pain relief can provide adequate relief with oral options, although difficult-to-treat pain syndromes, requiring a more complex treatment approach, may also be observed.

Discrimination of acute lymphoblastic leukemia from systemic-onset juvenile idiopathic arthritis at disease onset

OBJECTIVE

To assess clinical and laboratory features that differentiate acute lymphoblastic leukemia from systemic juvenile idiopathic arthritis at disease onset.

METHODS

Fifty-seven leukemia patients with musculoskeletal involvement, without blasts on peripheral blood and without glucocorticoid therapy at disease onset and 102 systemic juvenile idiopathic arthritis patients (International League of Associations for Rheumatology criteria) were retrospectively evaluated. The following features were examined: fever, rheumatoid rash, arthritis, limb pain, hepatomegaly, splenomegaly, pericarditis, myocarditis, pleuritis, weight loss, bleeding, anemia, leukopenia, neutropenia, thrombocytopenia, erythrocyte sedimentation rate, and lactic dehydrogenase levels.

RESULTS

The median age at disease onset was significantly higher in leukemia patients than in those with systemic-onset juvenile idiopathic arthritis (5.8 vs. 3.8 years). In addition, the frequencies of limb pain, hepatomegaly, weight loss and hemorrhagic manifestations were significantly higher in leukemia patients than in systemic-onset juvenile idiopathic arthritis patients (70% vs. 1%, 54% vs. 32%, 30% vs. 8%, and 9% vs. 0%, respectively). Likewise, the frequencies of anemia, leukopenia, neutropenia, thrombocytopenia and high lactic dehydrogenase levels were statistically higher in leukemia patients than in patients with systemic-onset juvenile idiopathic arthritis (88% vs. 57%, 39% vs. 1%, 60% vs. 1%, 77% vs. 1%, and 56% vs. 14%, respectively). Remarkably, multivariate analysis revealed that limb pain (OR = 553; 95% CI = 46.48-6580.42) and thrombocytopenia (OR = 754.13; 95% CI = 64.57-8806.72) were significant independent variables that differentiated leukemia from systemic-onset juvenile idiopathic arthritis. The R2 of the Nagelkerke test was 0.91, and the Kaplan-Meier survival curves were similar for acute lymphoblastic leukemia patients with and without limb pain.

CONCLUSION

Our study emphasizes the importance of investigating leukemia in patients presenting with musculoskeletal manifestations and, in particular, limb pain associated with thrombocytopenia.

[Musculoskeletal pain: a common initial sign of acute lymphoblastic leukaemia]

Musculoskeletal pain is a common complaint in paediatrics usually due to benign diseases. Nevertheless neoplasms, particularly acute leukaemia, must be considered in the differential diagnosis. During the last 9 months 4 of the 9 patients diagnosed with acute leukaemia at our hospital presented with a limp, arthralgias, lumbar or bony pain. We describe these cases and review the clinical and analytical parameters that help to differentiate benign pain from that associated with a malignant disease. The early detection of these processes may represent a significant improvement in their prognosis.

Acute lymphoblastic leukemia masquerading as juvenile rheumatoid arthritis: diagnostic pitfall and association with survival

Acute lymphoblastic leukemia (ALL) often presents with osteoarthritic manifestations which may lead to misdiagnosis with juvenile rheumatoid arthritis (JRA). This study was designed to identify ALL patients with initial diagnosis of JRA, compare their clinicolaboratory characteristics and outcome with other ALL patients treated at our center. Case records of 762 patients with ALL were analyzed. Information regarding the clinical-demographic profile, therapy and outcome were recorded. Of the children, 49 (6.4%) had initial presentation mimicking JRA. Asymmetric oligoarthritis was the most common pattern of joint involvement. Majority presented with fever, pallor, arthritis, night pain, and bone pain. None of the routine prognostic factors including age, gender, lymphadenopathy, hepatosplenomegaly, total leukocytes count (TLC), and platelet count were significantly associated with relapse/death. The mean symptom-presentation interval (SPI), hemoglobin was significantly higher whilst the TLC was significantly lower in these patients compared to other ALL patients. The 5 year overall-survival was better than other patients with ALL (p = 0.06, by logrank test). Significantly longer SPI in these patients underscores the need for prompt and early investigations to rule out ALL in patients of JRA with atypical features and pointers of ALL. Children with ALL-mimicking JRA may belong to a subgroup of ALL with a better prognosis.

Advanced vertebral fracture among newly diagnosed children with acute lymphoblastic leukemia: results of the Canadian Steroid-Associated Osteoporosis in the Pediatric Population (STOPP) research program

Vertebral compression is a serious complication of childhood acute lymphoblastic leukemia (ALL). The prevalence and pattern of vertebral fractures, as well as their relationship to BMD and other clinical indices, have not been systematically studied. We evaluated spine health in 186 newly diagnosed children (median age, 5.3 yr; 108 boys) with ALL (precursor B cell: N = 167; T cell: N = 19) who were enrolled in a national bone health research program. Patients were assessed within 30 days of diagnosis by lateral thoraco-lumbar spine radiograph, bone age (also used for metacarpal morphometry), and BMD. Vertebral morphometry was carried out by the Genant semiquantitative method. Twenty-nine patients (16%) had a total of 75 grade 1 or higher prevalent vertebral compression fractures (53 thoracic, 71%; 22 lumbar). Grade 1 fractures as the worst grade were present in 14 children (48%), 9 patients (31%) had grade 2 fractures, and 6 children (21%) had grade 3 fractures. The distribution of spine fracture was bimodal, with most occurring in the midthoracic and thoraco-lumbar regions. Children with grade 1 or higher vertebral compression had reduced lumbar spine (LS) areal BMD Z-scores compared with those without (mean +/- SD, -2.1 +/- 1.5 versus -1.1 +/- 1.2; p < 0.001). LS BMD Z-score, second metacarpal percent cortical area Z-score, and back pain were associated with increased odds for fracture. For every 1 SD reduction in LS BMD Z-score, the odds for fracture increased by 80% (95% CI: 10-193%); the presence of back pain had an OR of 4.7 (95% CI: 1.5-14.5). These results show that vertebral compression is an under-recognized complication of newly diagnosed ALL. Whether the fractures will resolve through bone growth during or after leukemia chemotherapy remains to be determined.

An unusual presentation of pediatric acute lymphoblastic leukemia

Acute lymphoblastic leukemia (ALL) is one of the most common hematological malignancies occurring in children. We report an interesting case of ALL with an unusual presentation. This 3-year-old boy came with a 6 month history of multiple pathological fractures, generalized osteopenia and vertebral compression. All the possible causes responsible for this condition were ruled out. His complete blood count which was normal initially evolved into cytopenias. His physical examination revealed generalized lymphadenopathy and hepatosplenomegaly. The complete blood count showed pancytopenia with blasts in peripheral smear. Bone marrow aspirate was suggestive of B ALL. Pediatric ALL patients usually present with symptoms due to cytopenias, fever and bone pains. Although asymptomatic skeletal involvement may be seen in 40-60% of patients at presentation, pathological fractures and vertebral compressions are very rare. Therefore a high index of suspicion is needed to diagnose such cases. Moreover, these patients are usually associated with good prognostic features.

Musculoskeletal manifestations in pediatric acute leukemia

BACKGROUND

In children, acute leukemia (AL) at presentation can mimic several orthopaedic pathologies, so that a variable delay of the correct diagnosis is often reported.

METHODS

To define more clearly the clinical and radiological musculoskeletal manifestations of leukemia in children, 122 affected children referred from 1984 to 1999 to our Pediatric Onco-Hematologic Clinic were retrospectively reviewed. Average age at diagnosis was 6.6 years (from 7 months to 17 years). Seventy-three (60%) were boys and adolescent boys, 49 (40%) were girls and adolescent girls. One hundred two (83.6%) had acute lymphoblastic leukemia, 20 (16.4%) had acute myeloid leukemia. The mean follow-up was 8.2 years for the 104 survivors and 2.5 years for the 18 nonsurvivors. The chi2 test was used to perform the statistical analyses.

RESULTS

At presentation, complaints related to the musculoskeletal system were frequent (38.3%), including pain (34.4%), functional impairment (22.9%), limping (12.3%), swelling (10.6%), and joint effusion (5.7%). At presentation, 40.2% of children had at least 1 radiographic abnormality. In order, they were osteolysis (13.1%), metaphyseal bands (9.8%), osteopenia (9%), osteosclerosis (7.4%), permeative pattern (5.7%), pathological fractures (5.7%), periosteal reactions (4.1%), and mixed lysis-sclerosis lesions (2.5%). Different from previous reports, late radiographic lesions were uncommon (5.7%), probably because of milder newer medication protocols. They included avascular necrosis (3.3%), vertebral collapses (1.6%), and osteolysis (0.8%).

CONCLUSIONS

Both clinical and radiological changes had various and no uniform localization. Poor correlation was found between symptoms and radiological lesions. Survival rates in children with AL were 95.8% at 1 year, 89.6% at 3 years, 85.8% at 5 years, and 83.4% at 10 and at 13 years. Radiographic abnormalities (P = 0.400), type of leukemia (P = 0.291), sex (P = 0.245), and white blood cell count at presentation (P = 0.877) were not prognostic factors. The presence of multiple bone lesions did not affect the survival rate (P=0.632). As early diagnosis significantly decreases morbidity and mortality of AL, the orthopaedist should suspect AL in any child with unexplained persistent skeletal pain or radiographic alterations. Accurate history, general physical examination, and complete blood cell count tests should address the suspicion, which is confirmed by a peripheral and/or iliac crest bone marrow biopsy.

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.

Osteoarticular manifestations as initial presentation of acute leukemias in children and adolescents in Bahia, Brazil

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.

Pediatric malignancies presenting as a possible infectious disease

Background

The clinical, laboratory, and radiological features of malignancy can overlap with those of infection. The purpose of this study was to determine the findings in children who were initially thought to have an infectious disease but ultimately proved to have a malignancy.

Methods

The database of patients diagnosed with a malignancy in the Northern Alberta Children's Cancer Program (NACCP) January 1, 1993 to December 31, 2003 was merged with the database of inpatients referred to the infectious diseases service at the Stollery Children's Hospital and charts were reviewed on all patients referred to the infectious diseases consult service prior to the diagnosis of malignancy.

Results

An infectious diseases consultation for diagnosis was requested in 21 of 561 patients prior to the confirmation of malignancy, and 3 of these 21 patients had both infection and malignancy (leukemia (N = 13), lymphoma (N = 3), rhabdomyosarcoma (N = 1), Langerhan's cell histiocytosis (N = 1), fibrous histicocytosis (N = 1), ependymoma (N = 1), and neuroblastoma (N = 1). The most common reason for infectious diseases consultation was suspected muskuloskeletal infection (N = 9). A palpable or radiographically enlarged spleen was noted in 11 patients (52%). All but 2 patients had abnormal hematologic parameters while an elevated lactate dehydrogenase (LDH) occurred in 10 patients (48%). Delay of diagnosis because of investigation or therapy for an infectious disease occurred in only 2 patients.

Conclusion

It is not common for treatment of pediatric malignancies to be delayed because infection is thought to be the primary diagnosis. However, pediatric infectious diseases physicians should consider malignancy in the differential diagnosis when they see patients with fever and bone pain, unexplained splenomegaly or abnormal complete blood cell counts. Other clues may include hepatomegaly or elevated LDH.

Acute lymphoblastic leukemia in children: correlation of musculoskeletal manifestations and immunophenotypes

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.

Difficult Pain Syndromes

Cancer pain is prevalent in approximately two thirds of all cancer patients and can undermine the quality of life in this patient population. Uncontrolled pain can cause physical as well as psychological distress in cancer patients. As the disease progresses in cancer, pain and suffering increase. Knowledge about pain management is paramount in the comprehensive treatment of cancer patients. Difficult cancer pain syndromes may arise from interruption of bone, viscera, and neural structures by malignant spread of the disease. Familiarity with opioids, adjuvants, and procedures that can abate pain in cancer patients is discussed in a practical manner for clinical application in this text.

A multicenter case-control study on predictive factors distinguishing childhood leukemia from juvenile rheumatoid arthritis

OBJECTIVE

Acute lymphocytic leukemia (ALL) often presents with musculoskeletal concerns such as pain or swelling, even before appearance of blasts in the peripheral blood. Such presentation may lead to misdiagnosis of a child with juvenile rheumatoid arthritis (JRA). This study was designed to identify the predictive factors for leukemia using basic clinical and laboratory information.

METHODS

A retrospective chart review was performed using a simple questionnaire to compare the clinical and laboratory findings present during the initial visit to a pediatric rheumatology clinic for 277 children who were ultimately diagnosed with either JRA (n = 206) or ALL (n = 71). Sensitivity and specificity analysis of a variety of parameters, both singly and in combination, was performed to identify predictive value for ALL.

RESULTS

The majority (75%) of children with ALL did not have blasts in the peripheral blood at the time of evaluation by pediatric rheumatologists. In children presenting with unexplained musculoskeletal complaints, the 3 most important factors that predicted a diagnosis of ALL were low white blood cell count (< 4 x 10(9)/L), low-normal platelet count (150-250 x 10(9)/L), and history of nighttime pain. In the presence of all 3, the sensitivity and specificity for a diagnosis of ALL were 100% and 85%, respectively. Other findings, including antinuclear antibody, rash, and objective signs of arthritis, were not helpful in differentiating between these diagnoses because they occurred at similar rates in both groups.

CONCLUSIONS

When a child develops new-onset bone-joint complaints, the presence of subtle complete blood count changes combined with nighttime pain should lead to consideration of leukemia as the underlying cause.

Musculoskeletal conditions of acute leukemia and malignant lymphoma in children

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.

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.

Osteoporosis in survivors of acute lymphoblastic leukemia

Osteoporosis is currently receiving increasing attention as an important late effect in survivors of childhood cancer and its treatment because of their quality of life and its negative effect on the survivors' ability to perform developmentally appropriate activities. Survivors of childhood cancer are especially vulnerable because they are affected during childhood and adolescence, a time when peak bone mass should be achieved. This paper reviews decreased bone density in acute lymphoblastic leukemia (ALL), which is the most common childhood cancer and has a cure rate approaching 80%. Osteopenia/osteoporosis has been observed in all phases of the disease: at diagnosis, during treatment, and throughout the post-treatment period for as long as 20 years. Among the findings that have been described are musculoskeletal pain, disturbed gait, fractures, kyphosis, lordosis, and growth failure. Risk factors not specifically related to ALL include smoking, ingestion of carbonated beverages, and family history of "brittle bone" or fractures. Patients should be counseled in regard to diet, exercise, smoking cessation, and avoidance of carbonated beverages. There are a number of options for specific drug therapy; however, the administration of bisphosponates to children and adolescents must be approached with caution. Research is needed to determine how extensive the problem is and how to best prevent and treat the osteopenia/osteoporosis associated with ALL.

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.

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.

"Refuses to walk" as an ED presentation of acute childhood leukemia

New onset of childhood acute leukemia may present to the emergency department in a variety of ways. This report describes the case of a 3-year-old boy who refused to walk and had minimal physical findings, normal X-rays, and nearly normal lab screening results. His white blood cell count differential led to the diagnosis of acute leukemia. The presentation and evaluation of acute leukemia in children is reviewed. Emergency physicians must be prepared to rule out malignancy in the child who refuses to walk when other more common causes, such as infection and trauma, seem unlikely.

Clinical and prognostic implications of bone lesions in childhood leukemia at diagnosis

We studied 168 children with acute lymphoblastic leukemia (ALL) and 57 with acute nonlymphoblastic leukemia (ANLL) by retrospectively analyzing clinical symptoms, bone or joint involvement, and hematological findings to verify the clinical features and prognosis of children with acute leukemia who showed radiographic bone changes at the time of diagnosis. Of these, 36 with ALL (21.4%) and 6 with ANLL (10.5%) had symptoms referable to the bones or joints. Thirteen patients (7.7%) with ALL showed bone lesions radiographically. Phenotypically, 12 of the 13 had common ALL, 8 were incorrectly diagnosed and had received treatment for osteomyelitis or juvenile rheumatoid arthritis for 1 to 7 months prior to diagnosis of ALL. Leukocyte count was nearly normal with few or no blasts, and anemia and thrombocytopenia were mild or absent in all patients. Twelve of them remained in a complete remission for 26 to 148 months. Our data suggest that children with bone lesions related to acute leukemia exhibit clinical features that mimic infectious or collagen disease at diagnosis, and may belong to a subgroup of ALL with a better prognosis.

Acquired immobility of the right arm

The occurrence of an asymmetrical motor dysfunction is an event that frequently results in referral to the pediatric neurologist. The differential diagnosis is not extensive but is somewhat larger than superficial evaluation might indicate. This 4-year-old boy developed intermittent painful motor dysfunction of the right arm over a 1-year period of time resulting from an unusual cause of unilateral motor dysfunction.

Clinicopathologic correlates of common cancer pain syndromes

The development of a treatment strategy for the management of cancer pain is based on a patient evaluation that elucidates the pain syndrome and predominant pathophysiological mechanism responsible for the pain. Coupled with evaluation of pain intensity, and the extent of functional and emotional disturbance, this assessment facilitates appropriate selection of primary and analgesic therapies to address the problem of patient distress.

Differentiation of systemic juvenile rheumatoid arthritis from acute leukemia near the onset of disease

Many children with acute leukemia have musculoskeletal complaints and non-specific hematologic abnormalities. A total of 10 children with acute leukemia and 10 with systemic juvenile rheumatoid arthritis were compared to delineate which early features could differentiate these diagnoses. Attention to evolving hematologic abnormalities and musculoskeletal findings may expedite diagnosis of these diseases.

Rheumatological manifestations of the leukaemias and graft versus host disease

Bone and joint involvement in the leukaemias is discussed. Particular emphasis is placed upon osteoarticular presentations which may predate the haematological changes or divert attention from the primary pathology. A description of acute and chronic graft versus host disease is presented with particular emphasis on the rheumatological manifestations.