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Torres Jimenez AR, Solis Vallejo E, Cespedes Cruz AI, Ramirez Miramontes JV, Cortina Olvera GDC, Velazquez Cruz A, Sanchez Jara B. Differences between leukemic arthritis and juvenile idiopathic arthritis. Pediatr Rheumatol Online J 2023; 21:50. [PMID: 37259088 DOI: 10.1186/s12969-023-00836-5] [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: 03/27/2023] [Accepted: 05/28/2023] [Indexed: 06/02/2023] Open
Abstract
OBJECTIVES To determine the clinical and laboratory differences between leukemic arthritis (LA) and juvenile idiopathic arthritis (JIA) at the onset of the disease. MATERIAL AND METHODS Patients under 16 years of age, both genders, who presented for the first time to the pediatric rheumatology service with a diagnosis of probable JIA, with arthritis and without peripheral blood blasts, in which the final diagnosis was acute lymphoblastic leukemia (ALL) or JIA. The clinical and laboratory characteristics of the patients were compared, chi-square and relative risk were used for categorical variables, and the Mann-Whitney U and T-test for the comparison of means between groups. A binary logistic regression model was developed to differentiate leukemic arthritis from JIA. RESULTS A total of 76 patients, 14 with LA and 62 with JIA, were analyzed. The mean age at diagnosis was lower in the leukemic arthritis group, the female gender prevailed in the JIA group, and the time to onset of symptoms was lower in the leukemic arthritis group. Patients with leukemic arthritis showed increased pain intensity, fever, weight loss, nocturnal diaphoresis, lymph node enlargement, hepatosplenomegaly, and pain that did not improve with analgesic administration. Laboratory parameters with statistical significance were the presence of anemia, leukopenia, and neutropenia. The platelet count was significant but in a low normal value, compared to the JIA. A binary logistic regression model was developed to differentiate leukemic arthritis from JIA. The probability associated with the statistic (Chi-square) was 0.000, and the Cox and Snell R2 and Nagelkerke R2 values were 0.615 and 1, respectively. The developed model correctly classified 100% of the cases. CONCLUSIONS The diagnosis of acute lymphoblastic leukemia should be ruled out in patients who present with arthritis and hematological alterations, mainly leukopenia and neutropenia, with joint pain disproportionate to the degree of arthritis, predominantly at night and that does not improve with the use of analgesics, fever, lymph nodes, and hepatosplenomegaly. Criteria are suggested to differentiate both diseases.
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Affiliation(s)
- Alfonso Ragnar Torres Jimenez
- Department of Pediatric Rheumatology, National Medical Center, La Raza, IMSS, Vallejo Y Jacarandas, Colonia La Raza, Azcapotzalco, Mexico City, 02990, México.
| | - Eunice Solis Vallejo
- Department of Pediatric Rheumatology, National Medical Center, La Raza, IMSS, Vallejo Y Jacarandas, Colonia La Raza, Azcapotzalco, Mexico City, 02990, México
| | - Adriana Ivonne Cespedes Cruz
- Department of Pediatric Rheumatology, National Medical Center, La Raza, IMSS, Vallejo Y Jacarandas, Colonia La Raza, Azcapotzalco, Mexico City, 02990, México
| | - Julia Veronica Ramirez Miramontes
- Department of Pediatric Rheumatology, National Medical Center, La Raza, IMSS, Vallejo Y Jacarandas, Colonia La Raza, Azcapotzalco, Mexico City, 02990, México
| | - Guadalupe Del Consuelo Cortina Olvera
- Department of Pediatric Rheumatology, National Medical Center, La Raza, IMSS, Vallejo Y Jacarandas, Colonia La Raza, Azcapotzalco, Mexico City, 02990, México
| | - Alejandra Velazquez Cruz
- Department of Pediatric Rheumatology, National Medical Center, La Raza, IMSS, Vallejo Y Jacarandas, Colonia La Raza, Azcapotzalco, Mexico City, 02990, México
| | - Berenice Sanchez Jara
- Department of Pediatric Hematology, National Medical Center La Raza, IMSS, Mexico City, México
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Civino A, Bovis F, Ponzano M, Alighieri G, Prete E, Sorrentino S, Magni-Manzoni S, Vinti L, Romano M, Santoro N, Filocamo G, Belotti T, Santarelli F, Gorio C, Cattalini M, Stabile G, Conter V, Rondelli R, Pession A, Ravelli A. Development and Initial Validation of the ONCOREUM Score to Differentiate Childhood Cancer with Arthropathy from Juvenile Idiopathic Arthritis. J Pediatr 2023; 253:219-224.e3. [PMID: 36202241 DOI: 10.1016/j.jpeds.2022.09.046] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/27/2022] [Revised: 09/24/2022] [Accepted: 09/28/2022] [Indexed: 11/11/2022]
Abstract
OBJECTIVE To develop and validate a weighted score, the ONCOREUM score, that aids physicians in differentiation of cancer with arthropathy from juvenile idiopathic arthritis (JIA). STUDY DESIGN Data were extracted from the ONCOREUM Study, a multicenter, cross-sectional investigation aimed at comparing children with cancer and arthropathy to children with JIA. Three statistical approaches were applied to develop the ONCOREUM score and assess the role of each variable in the diagnosis of cancer with arthropathy, including 2 approaches based on multivariable stepwise selection (models 1 and 2) and 1 approach on a Bayesian model averaging method (model 3). The β coefficients estimated in the models were used to assign score points. Considering that not missing a child with cancer is a mandatory clinical objective, discriminating performance was assessed by fixing sensitivity at 100%. Score performance was evaluated in both developmental and validation samples (representing 80% and 20% of the study population, respectively). RESULTS Patients with cancer and arthropathy (49 with solid tumors and 46 with hematologic malignancies without peripheral blasts) and 677 patients with JIA were included. The highest area under the receiver operating characteristic (ROC) curve (AUC) in the validation data set was yielded by model 1, which was selected to constitute the ONCOREUM score. The score ranged from -18 to 21.8, and the optimal cutoff obtained through ROC analysis was -6. The sensitivity, specificity, and AUC of the cutoff in the validation sample were 100%, 70%, and 0.85, respectively. CONCLUSIONS The ONCOREUM score is a powerful and easily applicable tool that may facilitate early differentiation of malignancies with articular complaints from JIA.
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Affiliation(s)
- Adele Civino
- Pediatric Rheumatology and Immunology, Hospital "Vito Fazzi", Lecce, Italy.
| | - Francesca Bovis
- Department of Health Sciences, Section of Biostatistics, University of Genova, Italy
| | - Marta Ponzano
- Department of Health Sciences, Section of Biostatistics, University of Genova, Italy
| | - Giovanni Alighieri
- Neonatology and Neonatal Intensive Care Unit, Hospital "A. Perrino", Brindisi, Italy
| | - Eleonora Prete
- Department of Hematology and Bone Marrow Transplant, Hospital "Card. G. Panico", Tricase, Italy
| | - Stefania Sorrentino
- Department of Paediatric Haemato-Oncology, Scientific Institute for Research, Hospitalization and Healthcare (IRCCS) Giannina Gaslini Institute, Genoa, Italy
| | | | - Luciana Vinti
- Department of Pediatric Hemato-Oncology, IRCCS Bambino Gesù, Rome, Italy
| | - Micol Romano
- Paediatric Rheumatology, Hospital and Orthopaedic Trauma Centre "G. Pini", Milan, Italy
| | - Nicola Santoro
- Department of Pediatric Oncology and Hematology, University "Aldo Moro" Bari, Italy
| | - Giovanni Filocamo
- Pediatric Rheumatology, IRCCS Ca' Granda Maggiore Hospital, Milan, Italy
| | - Tamara Belotti
- Pediatric Oncology and Haematology Unit, IRCCS, University of Bologna, Italy
| | - Francesca Santarelli
- Division of Pediatric Immunology and Rheumatology, Department of Public Health and Pediatrics, "Regina Margherita" Children Hospital, University of Turin, Italy
| | - Chiara Gorio
- Pediatric Oncohematology and Bone Marrow Transplant Unit, University of Brescia and "Spedali Civili", Brescia, Italy
| | - Marco Cattalini
- Pediatric Clinic, University of Brescia and "Spedali Civili", Brescia, Italy
| | - Giulia Stabile
- CINECA Interuniversity Consortium, Casalecchio di Reno, Italy
| | - Valentino Conter
- Pediatric Hematology-Oncology Unit, University of Milano-Bicocca, Monza, Italy
| | - Roberto Rondelli
- Pediatric Oncology and Haematology Unit, IRCCS, University of Bologna, Italy
| | - Andrea Pession
- Pediatric Unit, IRCCS S.Orsola-Malpighi Hospital, University of Bologna, Italy
| | - Angelo Ravelli
- Scientific Director, Giannina Gaslini Institute, Genoa, Italy; Department of Neurosciences, Rehabilitation, Ophthalmology, Genetics and Maternal-Infantile Sciences (DiNOGMI), University of Genoa, Italy
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Brix N, Amstrup J, Nørgaard M, Hagstrøm S, Hasle H, Herlin T. Musculoskeletal Diagnoses before Cancer in Children: A Danish Registry-Based Cohort Study. J Pediatr 2022; 242:32-38.e2. [PMID: 34798079 DOI: 10.1016/j.jpeds.2021.11.024] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2021] [Revised: 11/09/2021] [Accepted: 11/11/2021] [Indexed: 10/19/2022]
Abstract
OBJECTIVE To identify the prevalence of musculoskeletal diagnoses recorded 6 months before the diagnosis of cancer and to evaluate whether preceding musculoskeletal diagnoses affected survival. STUDY DESIGN We performed a nationwide registry-based cohort study including all children under 15 years of age diagnosed with cancer in Denmark over a 23-year period (1996-2018). The Danish National Patient Registry was used to identify musculoskeletal diagnoses and associated dates recorded within 6 months preceding the diagnosis of cancer. We compared the characteristics of children with and without a prior musculoskeletal diagnoses using prevalence ratios and 95% CI and diagnostic interval as median with IQR. We compared survival using Kaplan-Meier and Cox proportional hazards regression analysis adjusting for age, sex, and presence of metastasis at diagnosis. RESULTS Of 3895 children with all types of cancer, 264 (7%) had a total of 451 hospital visits with musculoskeletal diagnosis within 6 months preceding the diagnosis of cancer; however, survival was not affected. The overall median diagnostic interval from first musculoskeletal diagnosis (within 6 months before cancer diagnosis) to cancer diagnosis was 15 days (IQR, 7-47 days). A diagnosis of juvenile idiopathic arthritis, unspecified arthritis, and arthropathy each accounted for 5% of the contacts, primarily in children with acute lymphoblastic leukemia, bone sarcomas, or neuroblastomas. CONCLUSIONS A preliminary musculoskeletal diagnosis occurred in 7% of children with cancer, but did not affect the overall survival.
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Affiliation(s)
- Ninna Brix
- Department of Pediatric and Adolescent Medicine, Aarhus University Hospital, Aarhus, Denmark; Department of Pediatric and Adolescent Medicine, Aalborg University Hospital, Aalborg, Denmark.
| | - Jesper Amstrup
- Department of Pediatric and Adolescent Medicine, Aalborg University Hospital, Aalborg, Denmark
| | - Mette Nørgaard
- Clinical Epidemiology Department, Aarhus University Hospital, Aarhus, Denmark
| | - Søren Hagstrøm
- Department of Pediatric and Adolescent Medicine, Aalborg University Hospital, Aalborg, Denmark
| | - Henrik Hasle
- Department of Pediatric and Adolescent Medicine, Aarhus University Hospital, Aarhus, Denmark
| | - Troels Herlin
- Department of Pediatric and Adolescent Medicine, Aarhus University Hospital, Aarhus, Denmark
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Civino A, Alighieri G, Prete E, Caroleo AM, Magni-Manzoni S, Vinti L, Romano M, Santoro N, Filocamo G, Belotti T, Santarelli F, Gorio C, Ricci F, Colombini A, Pastore S, Cesaro S, Barone P, Verzegnassi F, Olivieri AN, Ficara M, Miniaci A, Russo G, Gallizzi R, Pericoli R, Breda L, Mura R, Podda RA, Onofrillo D, Lattanzi B, Tirtei E, Maggio MC, De Santis R, Consolini R, Arlotta A, La Torre F, Mainardi C, Pelagatti MA, Coassin E, Capolsini I, Burnelli R, Tornesello A, Soscia F, De Fanti A, Rigante D, Pizzato C, De Fusco C, Abate ME, Roncadori A, Rossi E, Stabile G, Biondi A, Lepore L, Conter V, Rondelli R, Pession A, Ravelli A. Musculoskeletal manifestations of childhood cancer and differential diagnosis with juvenile idiopathic arthritis (ONCOREUM): a multicentre, cross-sectional study. THE LANCET. RHEUMATOLOGY 2021; 3:e507-e516. [PMID: 38279403 DOI: 10.1016/s2665-9913(21)00086-2] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/21/2021] [Revised: 03/03/2021] [Accepted: 03/11/2021] [Indexed: 10/08/2023]
Abstract
BACKGROUND Presenting symptoms of childhood cancers might mimic those of rheumatic diseases. However, the evidence available to guide differential diagnosis remains scarce. Preventing wrong or delayed diagnosis is therefore important to avoid incorrect administration of glucocorticoid or immunosuppressive therapy and worsening of prognosis. As such, we aimed to assess the prevalence and characteristics of presenting musculoskeletal manifestations in patients at cancer onset and to identify the factors that differentiate childhood malignancies with arthropathy from juvenile idiopathic arthritis. METHODS We did a multicentre, cross-sectional study at 25 paediatric haemato-oncology centres and 22 paediatric rheumatology centres in Italy. We prospectively recruited patients who were younger than 16 years that were newly diagnosed with cancer or juvenile idiopathic arthritis. We excluded patients with glucocorticoid pre-treatment (>1 mg/kg per day of oral prednisone or equivalent for ≥2 consecutive weeks). We collected data for patients with a new diagnosis of cancer or juvenile idiopathic arthritis using an electronic case report form on a web-based platform powered by the Cineca Interuniversity Consortium. The primary outcome was to describe the frequency and characteristics of musculoskeletal manifestations at cancer onset; and the secondary outcome was to identify factors that could discriminate malignancies presenting with arthropathy, with or without other musculoskeletal symptoms, from juvenile idiopathic arthritis using multivariable logistic regression analysis. FINDINGS Between May 1, 2015, and May 31, 2018, 1957 patients were eligible, of which 1277 (65%) had cancer and 680 (35%) had juvenile idiopathic arthritis. Musculoskeletal symptoms occurred in 324 (25% [95% CI 23·0-27·8]) of 1277 patients with cancer, of whom 207 had arthropathy. Patients with malignant bone tumours had the highest frequency of musculoskeletal symptoms (53 [80%] of 66), followed by patients with Langerhans histiocytosis (16 [47%] of 34), leukaemia (189 [32%] of 582), soft-tissue sarcomas (16 [24%] of 68), and neuroblastoma (21 [19%] of 109). In the 324 patients with cancer and musculoskeletal symptoms, the most common complaints were joint pain (199 [61%]), followed by limb bone pain (112 [35%]). Joint involvement had a prevalent monoarticular pattern (100 [48%] of 207) and oligoarticular pattern (86 [42%] had 2-4 joints involved and 20 [10%] had >4 joints involved), with the most frequently involved joints being the hip (88 [43%] of 207) and knee (81 [39%]). On multivariable analysis, limb bone pain was the independent variable most strongly associated with cancer (odds ratio [OR] 87·80 [95% CI 18·89-408·12]), followed by weight loss (59·88 [6·34-565·53]), thrombocytopenia (12·67 [2·40-66·92]), monoarticular involvement (11·30 [4·09-31·19]), hip involvement (3·30 [1·13-9·61]), and male sex (2·40 [1·03-5·58]). Factors independently associated with juvenile idiopathic arthritis were morning stiffness (OR 0·04 [95% CI 0·01-0·20]), joint swelling (0·03 [0·01-0·09]), and involvement of the small hand joints (0·02 [0-1·05]). INTERPRETATION Our study provides detailed information about presenting musculoskeletal manifestations of childhood cancers and highlights the clinical and laboratory features that are most helpful in the differential diagnosis with juvenile idiopathic arthritis. FUNDING Associazione Lorenzo Risolo.
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Affiliation(s)
- Adele Civino
- Unità di Reumatologia e Immunologia Pediatrica, Ospedale Vito Fazzi, Lecce, Italy.
| | - Giovanni Alighieri
- Unità di Pediatra-UTIN, Azienda Ospedaliera Cardinale G Panico, Tricase, Italy
| | - Eleonora Prete
- Dipartimento di Ematologia, Azienda Ospedaliera Cardinale G Panico, Tricase, Italy
| | - Anna Maria Caroleo
- Dipartimento di Oncoematologia Pediatrica, IRCCS Istituto Giannina Gaslini, Genova, Italy
| | | | - Luciana Vinti
- Dipartimento di Oncoematologia Pediatrica, Ospedale Pediatrico Bambino Gesù IRCCS, Roma, Italy
| | - Micol Romano
- Divisione di Reumatologia, ASST G Pini-CTO, Milano, Italy
| | - Nicola Santoro
- Oncoematologia Pediatrica, Azienda Ospedaliero Universitaria Consorziale Policlinico di Bari, Bari, Italy
| | - Giovanni Filocamo
- Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico, Milano, Italy
| | - Tamara Belotti
- Clinica Pediatrica, Oncologia ed Ematologia Pediatrica Lalla Seràgnoli, Policlinico Sant'Orsola Malpighi, Bologna, Italy
| | - Francesca Santarelli
- Dipartimento di Pediatria, Ospedale Pediatrico Regina Margherita, AOU Città della Salute e della Scienza di Torino, Torino, Italy
| | - Chiara Gorio
- Unità di Oncoematologia Pediatrica e TMO, Spedali Civili, Brescia, Italy
| | | | - Antonella Colombini
- Unità di Oncoematologia Pediatrica, Fondazione MBBM/AO San Gerardo Clinica Pediatrica Universitaria, Monza, Italy
| | - Serena Pastore
- Dipartimento di Pediatria, Azienda Ospedaliera-Universitaria Integrata, Verona, Italy
| | - Simone Cesaro
- Oncoematologia Pediatrica, Dipartimento di Assistenza Integrata Materno Infantile, Azienda Ospedaliera-Universitaria Integrata, Verona, Italy
| | - Patrizia Barone
- Dipartimento di Pediatria, Azienda Ospedaliero Universitaria, Policlinico di Catania, Catania, Italy
| | - Federico Verzegnassi
- Unità di Oncoematologia Pediatrica, IRCCS Materno Infantile Burlo Garofolo, Trieste, Italy
| | - Alma Nunzia Olivieri
- Dipartimento della donna, del bambino e di chirurgia generale e specialistica, Università degli Studi della Campania Luigi Vanvitelli, Napoli, Italy
| | - Monica Ficara
- Divisione di Oncoematologia Pediatrica, Ospedale Policlinico, Modena, Italy
| | - Angela Miniaci
- Clinica Pediatrica, Policlinico Sant'Orsola Malpighi, Bologna, Italy
| | - Giovanna Russo
- Unità di Oncoematologia Pediatrica, Dipartimento di Medicina Clinica e Sperimentale, Università di Catania, Italy
| | - Romina Gallizzi
- Unità di Pediatria, Azienda Ospedaliera Universitaria Gaetano Martino, Messina, Italy
| | | | - Luciana Breda
- Reumatologia Pediatrica, Università di Chieti, Italy
| | - Rossella Mura
- Oncoematologia Pediatrica, Azienda Ospedaliera Brotzu, Cagliari, Italy
| | | | - Daniela Onofrillo
- Unità di Oncoematologia Pediatrica, Dipartimento di Ematologia, Ospedale di Pescara, Italy
| | - Bianca Lattanzi
- Azienda Ospedaliera Universitaria, Ospedale Pediatrico G Salesi, Ancona, Italy
| | - Elisa Tirtei
- SC Oncologia Pediatrica, Ospedale Infantile Regina Margherita, AOU Città della Salute e della scienza, Università di Torino, Italy
| | | | - Raffaela De Santis
- Dipartimento di Pediatria, Unità di Oncoematologia Pediatrica, Ospedale Casa Sollievo della Sofferenza, San Giovanni Rotondo, Italy
| | - Rita Consolini
- Dipartimento di Pediatria, Università di Pisa, Pisa, Italy
| | - Annalisa Arlotta
- Unità di Oncoematologia Pediatrica, Azienda Ospedaliero Universitaria di Parma, Italy
| | - Francesco La Torre
- Reumatologia Pediatrica, Azienda Ospedaliero Universitaria Consorziale Policlinico di Bari-Ospedale Pediatrico Giovanni XXIII, Bari, Italy
| | - Chiara Mainardi
- DIDAS Salute della Donna e del Bambino, Divisione di Oncoematologia Pediatrica e Trapianto di cellule ematopoietiche, Azienda Ospedaliera Universitaria di Padova, Padova, Italy
| | | | - Elisa Coassin
- SOSD Oncologia del Giovane e Radioterapia Pediatrica, Centro di Riferimento Oncologico di Aviano (CRO) IRCCS, Aviano, Italy
| | - Ilaria Capolsini
- A O U S M Della Misericordia, Oncoematologia Pediatrica con TCSE, Perugia, Italy
| | - Roberta Burnelli
- Unità di Oncoematologia Pediatrica, Azienda Ospedaliero Universitaria Sant'Anna di Ferrara, Cona, Italy
| | | | - Francesca Soscia
- Unità di Pediatria, Ospedale Santa Maria della Stella, Orvieto, Italy
| | | | - Donato Rigante
- Dipartimento di Scienze della Vita e Sanità Pubblica, Fondazione Policlinico Universitario A Gemelli IRCCS, Roma, Italy; Università Cattolica Sacro Cuore, Roma, Italy
| | | | - Carmela De Fusco
- Dipartimento di Oncologia Pediatrica, AORN Santobono-Pausilipon, Napoli, Italy
| | | | - Andrea Roncadori
- Healthcare Administration, IRCCS-Istituto Romagnolo per lo Studio dei Tumori Dino Amadori-IRST, Meldola, FC, Italy
| | - Elisa Rossi
- Consorzio Interuniversitario Cineca, Casalecchio di Reno, Italy
| | - Giulia Stabile
- Consorzio Interuniversitario Cineca, Casalecchio di Reno, Italy
| | - Andrea Biondi
- Unità di Oncoematologia Pediatrica, Fondazione MBBM/AO San Gerardo Clinica Pediatrica Universitaria, Monza, Italy
| | - Loredana Lepore
- Dipartimento di Pediatria, Azienda Ospedaliera-Universitaria Integrata, Verona, Italy
| | - Valentino Conter
- Unità di Oncoematologia Pediatrica, Fondazione MBBM/AO San Gerardo Clinica Pediatrica Universitaria, Monza, Italy
| | - Roberto Rondelli
- Clinica Pediatrica, Oncologia ed Ematologia Pediatrica Lalla Seràgnoli, Policlinico Sant'Orsola Malpighi, Bologna, Italy
| | - Andrea Pession
- Clinica Pediatrica, Oncologia ed Ematologia Pediatrica Lalla Seràgnoli, Policlinico Sant'Orsola Malpighi, Bologna, Italy
| | - Angelo Ravelli
- Dipartimento di Neuroscienze, Riabilitazione, Oftalmologia, Genetica e Scienze Materno-Infantili (DiNOGMI), Università degli Studi di Genova, Genova, Italy; Clinica Pediatrica e Reumatologia, IRCCS Istituto Giannina Gaslini, Genova, Italy; Department of Pediatric Rheumatology, Sechenov First Moscow State Medical University, Moscow, Russian
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Boccuzzi E, Ferro VA, Cinicola B, Schingo PM, Strocchio L, Raucci U. Uncommon Presentation of Childhood Leukemia in Emergency Department: The Usefulness of an Early Multidisciplinary Approach. Pediatr Emerg Care 2021; 37:e412-e416. [PMID: 30461671 DOI: 10.1097/pec.0000000000001694] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
ABSTRACT Leukemia is the most common childhood malignancy, and it is often characterized by pallor, fatigue, cytopenia, and organomegaly; sometimes musculoskeletal symptoms, mainly characterized by diffuse bone pain in the lower extremities, are the onset clinical characteristics of the disease. In these cases, the disease may initially be misdiagnosed as reactive arthritis, osteomyelitis, or juvenile idiopathic arthritis delaying appropriate diagnosis and management. Even if leukopenia, thrombocytopenia, and a history of nighttime pain are reported to be the most important predictive factors for a pediatric leukemia, blood examinations can sometimes be subtle or within normal limits, and this represents a further diagnostic difficulty. Radiological findings of leukemic bone involvement are described in patients with musculoskeletal symptoms of acute lymphoblastic leukemia and often appear before hematologic anomalies, but they are not specific for the disease. However, they could be helpful to get the right diagnosis if integrated with other features; thus, it is important knowing them, and it is mandatory for the multidisciplinary comparison to talk about dubious cases even in an emergency setting. We describe 4 patients visited in the emergency department for musculoskeletal complaints and having radiological lesions and a final diagnosis of acute lymphoblastic leukemia, in whom the onset of the manifestations could mimic orthopedic/rheumatologic diseases.
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Affiliation(s)
- Elena Boccuzzi
- From the Emergency Pediatric Department, Bambino Gesù Children's Hospital, IRCCS
| | - Valentina A Ferro
- From the Emergency Pediatric Department, Bambino Gesù Children's Hospital, IRCCS
| | - Bianca Cinicola
- Department of Pediatrics, Child Neurology and Psychiatry, Sapienza University of Rome
| | | | - Luisa Strocchio
- Pediatric Hematology and Oncology, Bambino Gesù Children's Hospital, IRCCS, Rome, Italy
| | - Umberto Raucci
- From the Emergency Pediatric Department, Bambino Gesù Children's Hospital, IRCCS
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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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Identifying acute lymphoblastic leukemia mimicking juvenile idiopathic arthritis in children. PLoS One 2020; 15:e0237530. [PMID: 32780759 PMCID: PMC7418991 DOI: 10.1371/journal.pone.0237530] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2020] [Accepted: 07/28/2020] [Indexed: 02/07/2023] Open
Abstract
Objective Acute lymphoblastic leukemia (ALL) may present with arthritis implying the risk of being misdiagnosed as juvenile idiopathic arthritis (JIA). The aim of this study was to identify predictors for ALL based on clinical and laboratory information. Methods This cross-sectional, retrospective study compared clinical presentation and laboratory results of 26 children with ALL and arthritis versus 485 children with JIA (433 non-systemic, 52 systemic JIA). Using a Bayesian score approach the findings were evaluated by calculating odds ratios (OR) and lnOR as a measure of diagnostic weight. Results Distinction on clinical grounds was difficult, as even a high number of joints involved did not exclude ALL. One or more hematologic cell counts were low (Hb <10 g/dL, platelet count <100 x 109/L, neutrophil count < 1.0 x 109/L) in 92% with ALL, 25% with systemic JIA and 10% with non-systemic JIA. Neutropenia and thrombocytopenia had the highest ORs of 128 (95% CI 43–387) and 129 (95% CI 26–638), each giving a diagnostic weight of 4. The estimated risks of ALL were 0.2% with normal cell counts and 9%, 67% and 100% when one, two or three cell lines were affected. Conclusion A simple count of cell lines with low counts can serve as a basic diagnostic strategy. Children with tri- or bilinear involvement should be referred to a bone marrow, and those with unilinear involvement a thorough screen for further evidence of ALL (organomegaly, ESR, LDH, uric acid, and blood smear).
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Louvigné M, Rakotonjanahary J, Goumy L, Tavenard A, Brasme JF, Rialland F, Baruchel A, Auclerc MF, Despert V, Desgranges M, Jean S, Faye A, Meinzer U, Lorrot M, Job-Deslandre C, Bader-Meunier B, Gandemer V, Pellier I. Persistent osteoarticular pain in children: early clinical and laboratory findings suggestive of acute lymphoblastic leukemia (a multicenter case-control study of 147 patients). Pediatr Rheumatol Online J 2020; 18:1. [PMID: 31898528 PMCID: PMC6941319 DOI: 10.1186/s12969-019-0376-8] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/09/2019] [Accepted: 10/29/2019] [Indexed: 01/01/2023] Open
Abstract
BACKGROUND The aim of this study was to identify early clinical and laboratory features that distinguish acute lymphoblastic leukemia (ALL) from juvenile idiopathic arthritis (JIA) in children presenting with persistent bone or joint pain for at least 1 month. METHODS We performed a multicenter case-control study and reviewed medical records of children who initially presented with bone or joint pain lasting for at least 1 month, all of whom were given a secondary diagnosis of JIA or ALL, in four French University Hospitals. Each patient with ALL was paired by age with two children with JIA. Logistic regression was used to compare clinical and laboratory data from the two groups. RESULTS Forty-nine children with ALL and 98 with JIA were included. The single most important feature distinguishing ALL from JIA was the presence of hepatomegaly, splenomegaly or lymphadenopathy; at least one of these manifestations was present in 37 cases with ALL, but only in 2 controls with JIA, for an odds ratio (OR) of 154 [95%CI: 30-793] (regression coefficient: 5.0). If the presence of these findings is missed or disregarded, multivariate analyses showed that non-articular bone pain and/or general symptoms (asthenia, anorexia or weight loss) (regression coefficient: 4.8, OR 124 [95%CI: 11.4-236]), neutrophils < 2 × 109/L (regression coefficient: 3.9, OR 50 [95%CI: 4.3-58]), and platelets < 300 × 109/L (regression coefficient: 2.6, OR 14 [95%CI: 2.3-83.9]) were associated with the presence of ALL (area under the ROC curve: 0.96 [95%CI: 0.93-0.99]). CONCLUSIONS Based on our findings we propose the following preliminary decision tree to be tested in prospective studies: in children presenting with at least 1 month of osteoarticular pain and no obvious ALL in peripheral smear, perform a bone marrow examination if hepatomegaly, splenomegaly or lymphadenopathy is present. If these manifestations are absent, perform a bone marrow examination if there is fever or elevated inflammatory markers associated with non-articular bone pain, general symptoms (asthenia, anorexia or weight loss), neutrophils < 2 × 109/L or platelets < 300 × 109/L.
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Affiliation(s)
- Mathilde Louvigné
- Unité d'Onco-Hémato-Immunologie pédiatrique, CHU Angers, 4 rue Larrey, 49933, Angers, France.
| | - Josué Rakotonjanahary
- 0000 0004 0472 0283grid.411147.6Unité d’Onco-Hémato-Immunologie pédiatrique, CHU Angers, 4 rue Larrey, 49933 Angers, France
| | - Laurence Goumy
- 0000 0004 0472 0283grid.411147.6Service de Pédiatrie générale, CHU Angers, Angers, France
| | - Aude Tavenard
- 0000 0001 2175 0984grid.411154.4Unité d’Onco-Hémato-Immunologie pédiatrique, CHU Rennes, Rennes, France
| | - Jean-François Brasme
- 0000 0004 0472 0283grid.411147.6Unité d’Onco-Hémato-Immunologie pédiatrique, CHU Angers, 4 rue Larrey, 49933 Angers, France
| | - Fanny Rialland
- 0000 0004 0472 0371grid.277151.7Unité d’Onco-Hémato-Immunologie pédiatrique, CHU Nantes, Nantes, France
| | - André Baruchel
- 0000 0001 2175 4109grid.50550.35Unité d’Hémato-Immunologie pédiatrique, CHU Robert Debré, Hôpitaux de Paris, Paris, France
| | - Marie-Françoise Auclerc
- 0000 0001 2175 4109grid.50550.35Unité d’Hémato-Immunologie pédiatrique, CHU Robert Debré, Hôpitaux de Paris, Paris, France ,Université de Paris, UFR Paris Diderot, Paris, France
| | - Véronique Despert
- 0000 0001 2175 0984grid.411154.4Service de Pédiatrie générale, CHU Rennes, Rennes, France
| | - Marie Desgranges
- 0000 0001 2175 0984grid.411154.4Service de Pédiatrie générale, CHU Rennes, Rennes, France
| | - Sylvie Jean
- 0000 0001 2175 0984grid.411154.4Service de Pédiatrie générale, CHU Rennes, Rennes, France
| | - Albert Faye
- Université de Paris, UFR Paris Diderot, Paris, France ,0000 0001 2175 4109grid.50550.35Service de Pédiatrie générale Maladies Infectieuses et Médecine Interne, Centre de référence des rhumatismes inflammatoires et maladies auto-immunes systémiques rares de l’enfant RAISE, CHU Robert Debré, Hôpitaux de Paris, Paris, France
| | - Ulrich Meinzer
- 0000 0001 2175 4109grid.50550.35Service de Pédiatrie générale Maladies Infectieuses et Médecine Interne, Centre de référence des rhumatismes inflammatoires et maladies auto-immunes systémiques rares de l’enfant RAISE, CHU Robert Debré, Hôpitaux de Paris, Paris, France
| | - Mathie Lorrot
- 0000 0001 2175 4109grid.50550.35Service de Pédiatrie générale Maladies Infectieuses et Médecine Interne, Centre de référence des rhumatismes inflammatoires et maladies auto-immunes systémiques rares de l’enfant RAISE, CHU Robert Debré, Hôpitaux de Paris, Paris, France
| | - Chantal Job-Deslandre
- 0000 0001 2175 4109grid.50550.35Service de Pédiatrie générale Maladies Infectieuses et Médecine Interne, Centre de référence des rhumatismes inflammatoires et maladies auto-immunes systémiques rares de l’enfant RAISE, CHU Robert Debré, Hôpitaux de Paris, Paris, France
| | - Brigitte Bader-Meunier
- 0000 0004 0593 9113grid.412134.1Unité d’Immuno-Hématologie et Rhumatologie Pédiatriques, Hôpital Necker-Enfants Malades, Hôpitaux de Paris, Paris, France
| | - Virginie Gandemer
- 0000 0001 2175 0984grid.411154.4Unité d’Onco-Hémato-Immunologie pédiatrique, CHU Rennes, Rennes, France
| | - Isabelle Pellier
- 0000 0004 0472 0283grid.411147.6Unité d’Onco-Hémato-Immunologie pédiatrique, CHU Angers, 4 rue Larrey, 49933 Angers, France
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Characteristics of children with acute lymphoblastic leukemia presenting with arthropathy. Clin Rheumatol 2018; 37:2455-2463. [DOI: 10.1007/s10067-018-4034-1] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2017] [Revised: 02/08/2018] [Accepted: 02/12/2018] [Indexed: 10/18/2022]
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Tsujioka T, Sugiyama M, Ueki M, Tozawa Y, Takezaki S, Ohshima J, Cho Y, Yamada M, Iguchi A, Kobayashi I, Ariga T. Difficulty in the diagnosis of bone and joint pain associated with pediatric acute leukemia; comparison with juvenile idiopathic arthritis. Mod Rheumatol 2017; 28:108-113. [PMID: 28612674 DOI: 10.1080/14397595.2017.1332474] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
OBJECTIVES Acute leukemia often causes osteoarthralgia. The aim of this study is characterization of leukemia-associated osteoarthralgia in comparison with juvenile idiopathic arthritis (JIA). METHODS We retrospectively reviewed clinical records of 31 patients with acute leukemia and 13 patients with articular JIA diagnosed between January 2008 and March 2013. Clinical and laboratory findings at the initial examination were compared among the three groups; 10 leukemia with and 21 leukemia without osteoarthralgia and 13 JIA groups. RESULTS Eleven of the 31 leukemic patients (35%) had osteoarthralgia before the diagnosis of leukemia. Peripheral leukemic cells were initially absent in 10 of the 31 leukemia patients including three with osteoarthralgia. Platelet counts over 300 × 109/L were common in JIA, but not in osteoarthralgia group. Mean serum lactate dehydrogenase levels were higher in both of the leukemia groups than JIA group but often within normal or near-normal levels in the leukemia groups. Magnetic resonance imaging was examined in three leukemic patients and demonstrated osteomyelitis-like bone marrow edema in two and periarticular infiltration similar to synovitis in one patient. Three leukemic patients with osteoarthralgia showed partial and transient responses to antibiotic therapy. CONCLUSIONS Leukemia-associated osteoarthralgia is often indistinguishable from rheumatic diseases by imaging and laboratory findings and should be confirmed by bone marrow examination.
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Affiliation(s)
- Takao Tsujioka
- a Department of Pediatrics , Hokkaido University Graduate School of Medicine , Sapporo , Japan
| | - Minako Sugiyama
- a Department of Pediatrics , Hokkaido University Graduate School of Medicine , Sapporo , Japan
| | - Masahiro Ueki
- a Department of Pediatrics , Hokkaido University Graduate School of Medicine , Sapporo , Japan
| | - Yusuke Tozawa
- a Department of Pediatrics , Hokkaido University Graduate School of Medicine , Sapporo , Japan
| | - Shunichiro Takezaki
- a Department of Pediatrics , Hokkaido University Graduate School of Medicine , Sapporo , Japan
| | - Junjiro Ohshima
- a Department of Pediatrics , Hokkaido University Graduate School of Medicine , Sapporo , Japan
| | - Yuko Cho
- a Department of Pediatrics , Hokkaido University Graduate School of Medicine , Sapporo , Japan
| | - Masafumi Yamada
- a Department of Pediatrics , Hokkaido University Graduate School of Medicine , Sapporo , Japan
| | - Akihiro Iguchi
- a Department of Pediatrics , Hokkaido University Graduate School of Medicine , Sapporo , Japan
| | - Ichiro Kobayashi
- a Department of Pediatrics , Hokkaido University Graduate School of Medicine , Sapporo , Japan.,b Center for Pediatric Allergy and Rheumatology , KKR Sapporo Medical Center , Sapporo , Japan
| | - Tadashi Ariga
- a Department of Pediatrics , Hokkaido University Graduate School of Medicine , Sapporo , Japan
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Këpuska AB, Spahiju L, Bejiq R, Manqestena R, Stavileci V, Ibraimi Z. THE DIFFERENTIAL ALGORITHM BETWEEN RHEUMATOLOGIC AND MALIGN DISEASES. Mater Sociomed 2016; 28:156-8. [PMID: 27147926 PMCID: PMC4851544 DOI: 10.5455/msm.2016.28.156-158] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2016] [Accepted: 03/15/2016] [Indexed: 11/12/2022] Open
Abstract
Objective: The aim of this study is to determine the differential algorithm between rheumatism and malignant diseases. For every pediatrician, to be warned when attending joint pain and child arthralgia and prevent and treat within time malignant diseases. Methods: Our case presented in Pediatric Clinic, was referred by Regional Hospital of Ferizaj with suspected diagnose of Febris Rheumatica and Arthralgia. The main complaint was joint pain. Initially the patient was admitted at Cardiology and Rheumatology department. Then after examinations was referred to Hemato-Oncology department. Hospitalized during the period from 12.12.2014 to 18.01.2015. Results: Bone marrow biopsy as terminal diagnostic tool reviled severe malignant hematologic disease, which was masked by clinical and lab findings as Febris Rheumatica. Conclusion: Arthralgia as one of child’s often complain, should have a special attention paid to, as it might be a warning sign for a lot of diseases. Steroid treatment should not be used before final diagnose of the disease and before rolling out hematologic etiology with peripheral blood smear.
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Affiliation(s)
| | - Lidvana Spahiju
- Pediatric Clinic, University Clinical Center of Kosovo, Prishtina, Kosovo
| | - Ramush Bejiq
- Pediatric Clinic, University Clinical Center of Kosovo, Prishtina, Kosovo
| | | | - Valbona Stavileci
- Pediatric Clinic, University Clinical Center of Kosovo, Prishtina, Kosovo
| | - Zana Ibraimi
- Department of Pharmacy, Faculty of Medicine, University of Prishtina, Kosovo
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Xu D, Xu G, Xu L, Cao H, Xu B, Chen W, Sun C, Yue L, Lin J. Acute lymphocytic leukemia mimicking spondyloarthritis in an adolescent: A case report and review of the literature. Oncol Lett 2015; 11:1143-1145. [PMID: 26893708 DOI: 10.3892/ol.2015.4026] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2014] [Accepted: 11/19/2015] [Indexed: 12/28/2022] Open
Abstract
The present study describes the case of an 18-year-old adolescent male exhibiting acute lymphocytic leukemia (ALL), complicated by the onset of the symptom of sacroiliitis mimicking spondyloarthritis. Atypical features including an enlarged spleen, poor effects of non-steroidal anti-inflammatory drug therapy, low levels of hemoglobin, a low platelet count, a low neutrophil count and increased levels of monocytes, indicated the possibility of hematological malignancy. Bone marrow examination confirmed the diagnosis of ALL. The patient received chemotherapy and the symptoms were dramatically relieved. To the best of our knowledge, the current study reports the second published case of a patient with ALL presenting with sacroiliitis. Sacroiliitis as an onset manifestation of ALL may result in misdiagnosis, therefore, a differential diagnosis is essential when atypical features are present.
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Affiliation(s)
- Danyi Xu
- Department of Rheumatology, The First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, Zhejiang 310003, P.R. China
| | - Guanhua Xu
- Department of Rheumatology, The First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, Zhejiang 310003, P.R. China
| | - Liqin Xu
- Department of Rheumatology, The First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, Zhejiang 310003, P.R. China
| | - Heng Cao
- Department of Rheumatology, The First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, Zhejiang 310003, P.R. China
| | - Bei Xu
- Department of Rheumatology, The First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, Zhejiang 310003, P.R. China
| | - Weiqian Chen
- Department of Rheumatology, The First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, Zhejiang 310003, P.R. China
| | - Chuanyin Sun
- Department of Rheumatology, The First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, Zhejiang 310003, P.R. China
| | - Lihuan Yue
- Department of Rheumatology, The First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, Zhejiang 310003, P.R. China
| | - Jin Lin
- Department of Rheumatology, The First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, Zhejiang 310003, P.R. China
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Morais SA, du Preez HE, Akhtar MR, Cross S, Isenberg DA. Musculoskeletal complications of haematological disease. Rheumatology (Oxford) 2015; 55:968-81. [DOI: 10.1093/rheumatology/kev360] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2015] [Indexed: 01/19/2023] Open
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Abstract
BACKGROUND At disease onset, children with acute lymphoblastic leukaemia (ALL) may present with arthralgia or even signs of arthritis. This might cause misdiagnosis and thereby lead to prolonged diagnostic delay. The present study aimed to identify children with ALL with joint involvement and to compare their characteristics and outcome with children with ALL without joint involvement. METHODS Case records of 286 children diagnosed with ALL between 1992 and 2013 were reviewed and analysed in this retrospective, descriptive study. RESULTS Fifty-three (18.5%) children with ALL presented with localised joint pain, and half of them had objective signs of arthritis. The mean number of joints involved was 2.5, most frequently presenting as asymmetric oligoarthritis. The suspected misdiagnosis were reactive arthritis (19/53), osteomyelitis (9/53) and juvenile idiopathic arthritis (8/53). Children with joint involvement had less objective signs of haematological disease. Cytopenia was absent in 24% in children with joint involvement (vs 8% without, p=0.001), 50% had only one cell line affected (vs 21%, p=0.0005) and 44% had no organomegaly (vs 29%, p=0.05). Median diagnostic delay was 4 vs 2 weeks. The 5-year event-free and overall survival was superior for children with joint involvement: 94% vs 87% (p=0.049), and 96% vs 83% (p=0.044). CONCLUSIONS ALL with joint involvement is a frequent finding (18.5%). The clinical signs of leukaemia are less prominent, but non-articular pain should alert the clinician of a possible diagnosis of leukaemia. The overall and event-free survivals were superior compared with the children without joint involvement.
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Affiliation(s)
- Ninna Brix
- Department of Pediatrics, Aarhus University Hospital Skejby, Aarhus, Denmark
| | - Steen Rosthøj
- Department of Pediatrics, Aalborg University Hospital, Aalborg, Denmark
| | - Troels Herlin
- Department of Pediatrics, Aarhus University Hospital Skejby, Aarhus, Denmark
| | - Henrik Hasle
- Department of Pediatrics, Aarhus University Hospital Skejby, Aarhus, Denmark
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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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Agodi A, Barchitta M, Trigilia C, Barone P, Marino S, Garozzo R, La Rosa M, Russo G, Di Cataldo A. Neutrophil counts distinguish between malignancy and arthritis in children with musculoskeletal pain: a case-control study. BMC Pediatr 2013; 13:15. [PMID: 23368751 PMCID: PMC3563449 DOI: 10.1186/1471-2431-13-15] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/13/2012] [Accepted: 01/15/2013] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND To identify the predictive factors for malignancies using basic clinical and laboratory information in children presenting with musculoskeletal pain and eventually diagnosed with juvenile idiopathic arthritis (JIA) or malignancy. METHODS A retrospective case-control chart review research examining laboratory data from patients referred for musculoskeletal pain in 2001-2010 and diagnosed with malignancy or JIA was performed. The validity of each test for the diagnosis of neoplasia was assessed by calculating the sensitivity, specificity, positive predictive values (PPV), negative predictive values (NPV) and likelihood ratios. RESULTS A total of 134 patients were enrolled. Statistically significant differences were found in neutrophil count, Hb, LDH, IgA and C4 values, ANA, anti-EA EBV IgG and anti-CMV IgG titres. High LDH value and anti-CMV IgG were the most predictive factors for neoplasia. High specificity factors for neoplasia were abnormal values of neutrophil count, Hb, IgA and C4, and the presence of anti-EA EBV and anti-CMV IgG. High PPV were recorded for abnormal neutrophil count, Hb value and anti-CMV titre. A low NPV was found only for anti-EA EBV and anti-CMV titres. CONCLUSIONS In this setting of patients, minimum changes in neutrophil count, particularly if associated with low Hb and high LDH levels, are to be thoroughly considered, because they appear as the most predictive factors for the diagnosis of tumour.
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Affiliation(s)
- Antonella Agodi
- Department GF Ingrassia, University of Catania, Via Santa Sofia 87, Catania 95123, Italy
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Arthropathy in haematological disorders in children. INDIAN JOURNAL OF RHEUMATOLOGY 2012. [DOI: 10.1016/s0973-3698(12)60028-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/19/2023] Open
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Migratory polyarthritis as a paraneoplastic syndrome in childhood leukemia. Rheumatol Int 2012; 33:1647-8. [PMID: 22218642 DOI: 10.1007/s00296-011-2345-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2011] [Accepted: 12/20/2011] [Indexed: 10/14/2022]
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Survival rates of children with acute lymphoblastic leukemia presenting to a pediatric rheumatologist in the United States. J Pediatr Hematol Oncol 2011; 33:424-8. [PMID: 21572344 DOI: 10.1097/mph.0b013e31820998c4] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
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.
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Arthritic presentation of childhood malignancy: beware of normal blood counts. Rheumatol Int 2010; 31:827-9. [PMID: 20686770 DOI: 10.1007/s00296-010-1584-1] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2010] [Accepted: 07/14/2010] [Indexed: 10/19/2022]
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