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Dybedokken A, Mathiesen R, Hasle H, Herlin T, Callesen MT, Hansen SH, Jensen LH, Amstrup J, Hagstrøm S, Brix N. Musculoskeletal misdiagnoses in pediatric patients with spinal tumors. Pediatr Blood Cancer 2024; 71:e31024. [PMID: 38706386 DOI: 10.1002/pbc.31024] [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: 11/01/2023] [Revised: 03/23/2024] [Accepted: 04/04/2024] [Indexed: 05/07/2024]
Abstract
OBJECTIVE Childhood spinal tumors often present with musculoskeletal symptoms, potentially causing a misdiagnosis and delays in diagnosis and treatment. This study aims to identify, characterize, and compare children with spinal tumors who had prior musculoskeletal misdiagnoses to those without, analyzing clinical presentation, diagnostic interval, and outcome. STUDY DESIGN This retrospective cohort study evaluated all children aged 0-14 years diagnosed with a spinal tumor in Denmark from 1996 to 2018. The cohort was identified through the Danish Childhood Cancer Registry, and the registry data were supplemented with data from medical records. The survival was compared using the Kaplan-Meier method. RESULTS Among 58 patients, 57% (33/58) received musculoskeletal misdiagnoses before the spinal tumor diagnosis. Misdiagnoses were mostly nonspecific (64%, 21/33), involving pain and accidental lesions, while 36% (12/33) were rheumatologic diagnoses. The patients with prior misdiagnosis had less aggressive tumors, fewer neurological/general symptoms, and 5.5 months median diagnostic interval versus 3 months for those without a misdiagnosis. Those with prior misdiagnoses tended to have a higher 5-year survival of 83% (95% confidence interval [CI]: 63%-92%) compared to 66% (95% CI: 44%-82%) for those without (p = .15). CONCLUSION Less aggressive spinal tumors may manifest as gradual skeletal abnormalities and musculoskeletal symptoms without neurological/general symptoms, leading to misdiagnoses and delays.
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Affiliation(s)
- Aurora Dybedokken
- Department of Pediatric and Adolescent Medicine, Aalborg University Hospital, Aalborg, Denmark
| | - Rene Mathiesen
- Department of Pediatric and Adolescent Medicine, Rigshospitalet, Copenhagen, 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
| | - Michael Thude Callesen
- Department of Pediatric and Adolescent Medicine, Odense University Hospital, Odense, Denmark
| | - Søren Holm Hansen
- Department of Pediatric and Adolescent Medicine, Odense University Hospital, Odense, Denmark
| | - Laura Hallundbæk Jensen
- Department of Pediatric and Adolescent Medicine, Aalborg University Hospital, Aalborg, Denmark
| | - Jesper Amstrup
- Department of Pediatric and Adolescent Medicine, Aalborg University Hospital, Aalborg, Denmark
| | - Søren Hagstrøm
- Department of Pediatric and Adolescent Medicine, Aalborg University Hospital, Aalborg, Denmark
| | - Ninna Brix
- Department of Pediatric and Adolescent Medicine, Aalborg University Hospital, Aalborg, Denmark
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Ye J, Zheng L, Chen Z, Wang Q, Liao X, Wang X, Wei Q, Bao Y. Serum α-hydroxybutyrate dehydrogenase as a biomarker for predicting survival outcomes in patients with UTUC after radical nephroureterectomy. BMC Urol 2024; 24:62. [PMID: 38509518 PMCID: PMC10953183 DOI: 10.1186/s12894-024-01439-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2023] [Accepted: 02/26/2024] [Indexed: 03/22/2024] Open
Abstract
PURPOSE We aimed to determine the prognostic value of α-hydroxybutyrate dehydrogenase (α-HBDH) in upper tract urothelial carcinoma (UTUC) patients after radical nephroureterectomy (RNU). MATERIALS AND METHODS We retrospectively enrolled the data of 544 UTUC patients at West China Hospital from May 2003 to June 2019. Cancer-specific survival (CSS) was the endpoint of interest. The optimal cutoff value of α-HBDH was identified by X-Tile program. After propensity score matching (PSM), we utilized Kaplan‒Meier curves to estimate survival and Cox proportional hazard model for risk assessment. A nomogram was built based on the results of multivariate analysis, and calibration curve, time-dependent receiver operating characteristic (ROC) curves and decision curve analysis were also performed to evaluate the predictive accuracy. RESULTS Overall, 394 and 150 patients were divided into the α-HBDH-low group and α-HBDH -high group at the cutoff value of 158 U/L, respectively. After PSM, the two groups were well matched for all confounding factors. High α-HBDH was associated with inferior CSS (P = 0.006), and preoperative α-HBDH was an independent predictor for CSS (HR: 1.36; 95% CI:1.08, 1.80), especially in localized UTUC patients (HR: 2.04; 95% CI:1.11, 3.74). Furthermore, the nomogram based on α-HBDH achieved great predictive ability for CSS with areas under the curves of 0.800 and 0.778 for 3-year and 5-year CSS, respectively. CONCLUSION Serum α-HBDH was a novel and reliable biomarker for predicting survival outcomes in UTUC patients after RNU but should be further explored.
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Affiliation(s)
- Jianjun Ye
- Department of Urology and Institute of Urology, West China Hospital, Sichuan University, Chengdu, 610041, China
- West China School of Medicine, Sichuan University, Chengdu, China
| | - Lei Zheng
- Department of Urology and Institute of Urology, West China Hospital, Sichuan University, Chengdu, 610041, China
- West China School of Medicine, Sichuan University, Chengdu, China
- Department of Urology, People's Hospital of Tibet Autonomous Region, Lhasa, China
| | - Zeyu Chen
- Department of Urology and Institute of Urology, West China Hospital, Sichuan University, Chengdu, 610041, China
| | - Qihao Wang
- Department of Urology and Institute of Urology, West China Hospital, Sichuan University, Chengdu, 610041, China
- West China School of Medicine, Sichuan University, Chengdu, China
| | - Xinyang Liao
- Department of Urology and Institute of Urology, West China Hospital, Sichuan University, Chengdu, 610041, China
| | - Xingyuan Wang
- Department of Urology and Institute of Urology, West China Hospital, Sichuan University, Chengdu, 610041, China
- West China School of Medicine, Sichuan University, Chengdu, China
| | - Qiang Wei
- Department of Urology and Institute of Urology, West China Hospital, Sichuan University, Chengdu, 610041, China.
| | - Yige Bao
- Department of Urology and Institute of Urology, West China Hospital, Sichuan University, Chengdu, 610041, China.
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Tumminelli C, Pastore S, Taddio A. Chronic limping in childhood, what else other than juvenile idiopathic arthritis: a case series. Pediatr Rheumatol Online J 2023; 21:142. [PMID: 38001451 PMCID: PMC10668342 DOI: 10.1186/s12969-023-00927-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/02/2023] [Accepted: 11/14/2023] [Indexed: 11/26/2023] Open
Abstract
BACKGROUND Limping is a common clinical symptom in childhood; different clinical conditions may lead to limping and the diagnosis of the underlying cause may often be a challenge for the pediatrician. CASE PRESENTATION We describe the clinical manifestations, radiological pictures and disease course of other causes of limping in childhood, through a case series of seven cases and a brief discussion of each disease. CONCLUSIONS although trauma is the most common cause of acute limping, when there is no history of traumatic events and the limping has a chronic course, Juvenile Idiopathic Arthritis is usually the most likely clinical diagnosis. However, other some rare conditions should be taken into account if JIA is not confirmed or if it presents with atypical clinical picture.
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Affiliation(s)
| | - Serena Pastore
- Institute for Maternal and Child Health IRCCS "Burlo Garofolo" (IRCCS), Trieste, Italy
| | - Andrea Taddio
- University of Trieste, Trieste, Italy.
- Institute for Maternal and Child Health IRCCS "Burlo Garofolo" (IRCCS), Trieste, Italy.
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Yuan ZM, Wang LH, Chen C. Prognostic value of serum α-HBDH levels in patients with lung cancer. World J Surg Oncol 2023; 21:78. [PMID: 36872314 PMCID: PMC9987145 DOI: 10.1186/s12957-023-02965-3] [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: 10/29/2022] [Accepted: 02/27/2023] [Indexed: 03/07/2023] Open
Abstract
BACKGROUND The purpose of our study is to investigate the expression level and prognostic value of serum α-hydroxybutyrate dehydrogenase (α-HBDH) in lung cancer (LC) patients. METHOD LC patients treated in the Department of Oncology, Shaanxi Provincial Cancer Hospital from January 2014 to December 2016 were included in this study, all of whom underwent serological detection of α-HBDH prior to admission, and were enrolled in follow-up 5-year survival. Comparing the differences between high group and normal groups based on α-HBDH and LDH expression via clinicopathological parameters and laboratory data. Univariate and multivariate regression and overall survival (OS) were analyzed to explore whether elevated α-HBDH was an independent risk factor for LC, compared to LDH. RESULTS Multivariate regression analysis showed that age (P = 0.018), liver metastasis (P = 0.011), α-HBDH (P = 0.015), and neutrophil-to-lymphocyte ratio (NLR) (P = 0.031) were independent prognostic factors affecting OS in LC patients. The overall diagnostic efficacy of α-HBDH (AUC = 0.887) was higher than that of LDH (AUC = 0.709) in the ROC curve. The sensitivity was significantly higher of α-HBDH (sensitivity: 76.06%, specificity: 94.87%) compared with LDH (sensitivity: 49.30%, specificity: 94.87%). The median of OS was more significant in the high-α-HBDH group (6.4 months) than in the normal-α-HBDH group (12.7 months) (P = 0.023). The median of OS was significant in the high-LDH (> 245 U/L) group at 5.8 months and 12.0 months in the normal-LDH (≤ 245 U/L) group (P = 0.068). CONCLUSIONS Elevated expression of α-HBDH may indicate a poor prognosis of LC patients. It has a higher sensitivity than LDH and can be used as a potential early biomarker and an independent risk factor predicting the prognosis of LC survival.
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Affiliation(s)
- Zhi-Min Yuan
- Department of Clinical Laboratory, Shaanxi Provincial Cancer Hospital, Xi'an, Shaanxi, China
| | - Long-Hao Wang
- Department of Otorhinolaryngology‑Head and Neck Surgery, Shanghai Ninth People's Hospital, Shanghai Jiaotong University, Shanghai, China
| | - Cheng Chen
- Department of General Dentistry/Key Laboratory of Shaanxi Province for Craniofacial Precision Medicine Research, College of Stomatology, Xi'an Jiaotong University, Xiwu Road 98# Xi'an, Shaanxi, 710004, China.
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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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Gorczyca D, Iwańczyk P, Staś K, Postępski J. Knee pain as a reason for referral to a paediatric rheumatologist: A retrospective study. J Paediatr Child Health 2023; 59:439-444. [PMID: 36627832 DOI: 10.1111/jpc.16309] [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: 08/29/2022] [Revised: 11/17/2022] [Accepted: 12/02/2022] [Indexed: 01/12/2023]
Abstract
AIM Knee pain is the most frequently reported type of lower extremity pain among children and adolescents. The objective of this study was to establish the features distinguishing inflammatory knee pain from non-inflammatory knee pain and to determine the specific variables to consider in suspected juvenile idiopathic arthritis (JIA). METHODS A retrospective chart review was performed among children with knee pain evaluated through paediatric rheumatology consultations at a single centre between 2012 and 2019. RESULTS Among the 262 children, 32 patients (12.2%) were diagnosed with JIA, 46 patients (17.6%) presented with inflammatory knee pain (IP) of an origin different than JIA, and 57 patients (21.7%) with non-inflammatory knee pain (NIP). In 127 cases (48.5%), no musculoskeletal disorder was diagnosed (NDD). The presence of limping, joint swelling, decreased passive range of motion and decreased active range of motion of the knee joint were registered more frequently in the JIA group compared to the other three groups. Multivariate analysis showed that a family history of autoimmune diseases and pain in other joints were associated with inflammatory pain. Increased pain after physical activity, pain only in the knee joint and absence of limping were predictors of NIP. The risk factors of JIA were limping and an erythrocyte sedimentation range of ≥10 mm after an hour. In the NDD group, the risk factors included no increase in pain after physical activity, serum C-reactive protein level < 5 mg/L and normal musculoskeletal ultrasound image. CONCLUSIONS The majority of children with knee pain referred to a paediatric rheumatologist do not have arthritis. Knee pain alone, as a chief complaint, rarely leads to a final JIA diagnosis. Further studies are necessary in order to design the appropriate diagnostic and therapeutic algorithms.
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Affiliation(s)
- Daiva Gorczyca
- Center for Chronically Sick Children Berlin, Charité Universitätsmedizin Berlin, Campus Virchow-Klinikum, Berlin, Germany
| | - Patrycja Iwańczyk
- Neonatology Department, The Institute of Mother and Child, Warsaw, Poland
| | - Karolina Staś
- Paediatric Department, Public Autonomous Health Care Hospital, Sulechów, Poland
| | - Jacek Postępski
- Department of Paediatric Pulmonology and Rheumatology, Medical University of Lublin, Lublin, Poland
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Fordham NJ, Bartram J, Ghorashian S, O'Connor D, Taylor A, Sibson K, Rao A, Pavasovic V, Cheng D, Ancliff P, Vora A, Samarasinghe S. What is the diagnostic yield of bone marrow aspiration to exclude leukaemia prior to systemic treatment in juvenile idiopathic arthritis? Br J Haematol 2022; 199:447-451. [PMID: 35974444 DOI: 10.1111/bjh.18413] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2022] [Revised: 08/04/2022] [Accepted: 08/07/2022] [Indexed: 11/30/2022]
Affiliation(s)
- Nicholas J Fordham
- Haematology Department, Great Ormond Street Hospital for Children, London, UK
| | - Jack Bartram
- Haematology Department, Great Ormond Street Hospital for Children, London, UK
| | - Sara Ghorashian
- Haematology Department, Great Ormond Street Hospital for Children, London, UK
| | - David O'Connor
- Haematology Department, Great Ormond Street Hospital for Children, London, UK.,Department of Haematology, University College London Cancer Institute, London, UK
| | - Alice Taylor
- Haematology Department, Great Ormond Street Hospital for Children, London, UK
| | - Keith Sibson
- Haematology Department, Great Ormond Street Hospital for Children, London, UK
| | - Anupama Rao
- Haematology Department, Great Ormond Street Hospital for Children, London, UK
| | - Vesna Pavasovic
- Haematology Department, Great Ormond Street Hospital for Children, London, UK
| | - Danny Cheng
- Haematology Department, Great Ormond Street Hospital for Children, London, UK
| | - Phil Ancliff
- Haematology Department, Great Ormond Street Hospital for Children, London, UK
| | - Ajay Vora
- Haematology Department, Great Ormond Street Hospital for Children, London, UK
| | - Sujith Samarasinghe
- Haematology Department, Great Ormond Street Hospital for Children, London, UK
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Sanchez-Mostiero DO, Boussati JMA. Low back pain as an unusual presentation in a child with acute lymphoblastic leukaemia. BMJ Case Rep 2022; 15:e242843. [PMID: 35246428 PMCID: PMC8900049 DOI: 10.1136/bcr-2021-242843] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/10/2022] [Indexed: 11/03/2022] Open
Abstract
Acute leukaemia is the most common childhood cancer. The clinical presentation of acute leukaemia includes fever, pallor, bleeding tendencies, hepatosplenomegaly, lymphadenopathy and bone pains. This case is about a 7-year-old boy who presented with 2 months of progressive low back pain after jumping into the sea. Radiologic workup showed compression fractures in the T6-L5 regions of the spine. Trauma and osteogenesis imperfecta were considered initially until the patient developed the classic features of leukaemia. Analysis of the bone marrow aspirate, 2 months after the sea incident, revealed B cell acute lymphoblastic leukaemia (ALL). The low back pain subsided after a week of chemotherapy. A symptom that involves bone pain in a child needs thorough evaluation because a delay in diagnosis affects the outcome of treatment. ALL has been lingering at the time of his accident and this has caused weakening of his spine that resulted in much more severe injury than would have occurred in the absence of the ALL.
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Affiliation(s)
- Daisy Olave Sanchez-Mostiero
- Department of Clinical Epidemiology, University of the Philippines, Manila, Philippines
- Department of Pediatrics, Batangas Medical Center, Batangas, Philippines
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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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11
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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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12
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Çakan M, Karadağ ŞG, Ayaz NA. Differential diagnosis portfolio of a pediatric rheumatologist: eight cases, eight stories. Clin Rheumatol 2020; 40:769-774. [PMID: 32656661 DOI: 10.1007/s10067-020-05287-x] [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: 05/20/2020] [Revised: 06/27/2020] [Accepted: 07/08/2020] [Indexed: 10/23/2022]
Abstract
There is no single diagnostic test for any rheumatic disease. The diagnosis of a rheumatic disease is made by the sum of the findings in history, physical examination, laboratory, and imaging tests. A differential diagnosis list in pediatric rheumatology is quite long and mainly includes malignant, infectious, and inherited metabolic disorders. We aim to present cases that were referred to a pediatric rheumatology outpatient clinic with provisional diagnosis of a rheumatic disease but finally diagnosed with a non-rheumatic disease in order to emphasize the importance of differential diagnoses. Eight cases were presented in this manuscript. Five cases were referred with the provisional diagnosis of juvenile idiopathic arthritis. Sarcoidosis, chronic non-bacterial osteomyelitis, and autoinflammatory disease were the provisional referral diagnoses in three patients. Definitive diagnoses of the patients were as follows: acute lymphoblastic leukemia (two cases), bilineage acute leukemia, Hodgkin lymphoma, brucellosis, mucolipidosis type III, anhidrotic ectodermal dysplasia, and Freiberg disease. In children presenting with rheumatic complaints malignant, infectious and inherited metabolic disorders should always be in the differential diagnosis list of a pediatric rheumatologist. Alternative diagnoses should always be considered even in patients with a rheumatic disease when the patient does not respond to treatment or follows an unusual clinical course. Key Points • Diagnosis of a rheumatic disease is made by exclusion of all other pathologies. • Malignant and infectious diseases may mimic the signs and symptoms of a rheumatic disease.
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Affiliation(s)
- Mustafa Çakan
- Istanbul Kanuni Sultan Süleyman Research and Training Hospital, Clinic of Pediatric Rheumatology, University of Health Sciences, 221.Sk Kucukcekmece, Atakent, 34303, Istanbul, Turkey. .,Atakent Mah. Kanuni Sultan Süleyman Research and Training Hospital, Halkalı Kucukcekmece, 34303, Istanbul, Turkey.
| | - Şerife Gül Karadağ
- Istanbul Kanuni Sultan Süleyman Research and Training Hospital, Clinic of Pediatric Rheumatology, University of Health Sciences, 221.Sk Kucukcekmece, Atakent, 34303, Istanbul, Turkey
| | - Nuray Aktay Ayaz
- Istanbul Kanuni Sultan Süleyman Research and Training Hospital, Clinic of Pediatric Rheumatology, University of Health Sciences, 221.Sk Kucukcekmece, Atakent, 34303, Istanbul, Turkey
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13
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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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14
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Chaber R, Gurgul A, Wróbel G, Tomoń A, Paszek S, Potocka N, Haus O, Lejman M, Łach K, Szmatoła T, Jasielczuk I, Rybka B, Ryczan-Krawczyk R, Stąpor S, Ciebiera K, Arthur CJ, Zawlik I. The distinguishable DNA whole genome methylation profile of 2 cases of pediatric precursor B acute lymphoblastic leukaemia (BCP ALL) with prodromal, preleukemic phase: A case report. Medicine (Baltimore) 2018; 97:e12763. [PMID: 30334962 PMCID: PMC6211912 DOI: 10.1097/md.0000000000012763] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
RATIONALE A prolonged, prodromal phase before definitive paediatric precursor B acute lymphoblastic leukaemia (BCP ALL) diagnosis is rarely observed. PATIENTS CONCERNS In the first, the patient presented with an aplastic preleukemic phase, whilst the second presented with a rheumatic-like preliminary phase. DIAGNOSES The case reports of two patients with BCP ALL with a prodromal phase lasting a few weeks are presented. INTERVENTIONS AND OUTCOMES DNA whole genome profile methylation analysis of bone marrow cells obtained at diagnosis revealed a pattern of methylation that was readily distinguishable from both healthy and standard course BCP ALL bone marrow samples. LESSONS The biological implication of this observation remains unclear, with many differentially methylated loci involved in many processes like neurogenesis, cell projection organization and adhesion along with leucocyte activation and apoptosis. The prevalence and clinical significance of these methylation changes is unknown but this data indicates that the epigenetic basis of BCP ALL with a prolonged, prodromal phase requires a more detailed assessment.
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Affiliation(s)
- Radosław Chaber
- Department of Pediatric Hematooncology, Faculty of Medicine, University of Rzeszow, Rzeszow
| | - Artur Gurgul
- National Research Institute of Animal Production, Laboratory of Genomics, Balice
| | - Grażyna Wróbel
- Department of Paediatric Bone Marrow Transplantation, Oncology and Hematology, Medical University of Wroclaw, Wroclaw
| | - Anna Tomoń
- Department of Pediatric Hematooncology, Faculty of Medicine, University of Rzeszow, Rzeszow
| | - Sylwia Paszek
- Laboratory of Molecular Biology, Centre for Innovative Research in Medical and Natural Sciences, Faculty of Medicine, University of Rzeszow, Rzeszow
| | - Natalia Potocka
- Laboratory of Molecular Biology, Centre for Innovative Research in Medical and Natural Sciences, Faculty of Medicine, University of Rzeszow, Rzeszow
| | - Olga Haus
- Department of Clinical Genetics, Faculty of Medicine, Collegium Medicum in Bydgoszcz, Bydgoszcz, Nicolaus Copernicus University in Torun, Torun
| | - Monika Lejman
- Department of Pediatric, Hematology, Oncology and Bone Marrow Transplantation, Medical University of Lublin, Lublin
| | - Kornelia Łach
- Department of Pediatric Hematooncology, Faculty of Medicine, University of Rzeszow, Rzeszow
| | - Tomasz Szmatoła
- National Research Institute of Animal Production, Laboratory of Genomics, Balice
| | - Igor Jasielczuk
- National Research Institute of Animal Production, Laboratory of Genomics, Balice
| | - Blanka Rybka
- Department of Paediatric Bone Marrow Transplantation, Oncology and Hematology, Medical University of Wroclaw, Wroclaw
| | - Renata Ryczan-Krawczyk
- Department of Paediatric Bone Marrow Transplantation, Oncology and Hematology, Medical University of Wroclaw, Wroclaw
| | | | | | | | - Izabela Zawlik
- Laboratory of Molecular Biology, Centre for Innovative Research in Medical and Natural Sciences, Faculty of Medicine, University of Rzeszow, Rzeszow
- Department of Genetics, Institution of Experimental and Clinical Medicine, Faculty of Medicine, University of Rzeszow, Rzeszow, Poland
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15
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Neuroblastoma metastasis to bone requiring differentiation from septic arthritis of the hip. Report of 2 cases. J Orthop Sci 2018; 23:853-856. [PMID: 27680582 DOI: 10.1016/j.jos.2016.09.004] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/16/2015] [Revised: 08/11/2016] [Accepted: 09/09/2016] [Indexed: 11/22/2022]
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16
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Abstract
This article focuses on creating an orderly approach to history taking, examination, and ordering appropriate investigations when caring for a child with joint complaints. It classifies complaints as those with and without pain, swelling, or fever and of short or long duration. It recommends an approach to the physical examination and both suggests and discourages various laboratory and imaging studies.
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Affiliation(s)
- Kathleen A Haines
- Pediatric Immunology, Section of Pediatric Rheumatology and Immunology, Department of Pediatrics, Seton Hall-Hackensack Meridian School of Medicine, Hackensack University Medical Center, 30 Prospect Avenue, Room WFAN 360, Hackensack, NJ 07601, USA.
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17
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da Silva SA, Mendes J, Carvalho J, Nogueira H, Barroca H, Fernandes M, Tomás E. Irritable Hip as the Inaugural Symptom for Neuroblastoma. Case Rep Orthop 2018; 2018:7428350. [PMID: 30050714 PMCID: PMC6046166 DOI: 10.1155/2018/7428350] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2018] [Accepted: 06/06/2018] [Indexed: 11/24/2022] Open
Abstract
CASE REPORT A four-year-old girl presented with fever and a painful limp in the left hip. Pain characteristics and anemia detected in the blood analyses were the first warning signs that the hip process was not standard. Although the primary suspicion was of septic arthritis, a CT scan of the abdomen revealed an adrenal neuroblastoma. CONCLUSION The presenting signs of neuroblastoma are commonly atypical. About 25% of presentations are orthopedic and mimic a variety of severe orthopedic conditions. The most important clinical dilemma is distinguishing benign and self-limiting disorders from septic or malignant processes.
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Affiliation(s)
- Sara Alves da Silva
- Orthopedics and Trauma Department, Centro Hospitalar Tâmega e Sousa, Guilhufe, Portugal
| | - Jorge Mendes
- Orthopedics and Trauma Department, Centro Hospitalar Tâmega e Sousa, Guilhufe, Portugal
| | - João Carvalho
- Orthopedics and Trauma Department, Centro Hospitalar Tâmega e Sousa, Guilhufe, Portugal
| | - Hélder Nogueira
- Orthopedics and Trauma Department, Centro Hospitalar Tâmega e Sousa, Guilhufe, Portugal
| | - Helena Barroca
- Biopathology Department, Centro Hospitalar São João, Porto, Portugal
| | | | - Edite Tomás
- Pediatrics Department, Centro Hospitalar Tâmega e Sousa, Guilhufe, Portugal
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18
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Hinze CH, Holzinger D, Lainka E, Haas JP, Speth F, Kallinich T, Rieber N, Hufnagel M, Jansson AF, Hedrich C, Winowski H, Berger T, Foeldvari I, Ganser G, Hospach A, Huppertz HI, Mönkemöller K, Neudorf U, Weißbarth-Riedel E, Wittkowski H, Horneff G, Foell D. Practice and consensus-based strategies in diagnosing and managing systemic juvenile idiopathic arthritis in Germany. Pediatr Rheumatol Online J 2018; 16:7. [PMID: 29357887 PMCID: PMC5778670 DOI: 10.1186/s12969-018-0224-2] [Citation(s) in RCA: 53] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/08/2017] [Accepted: 01/12/2018] [Indexed: 01/06/2023] Open
Abstract
BACKGROUND Systemic juvenile idiopathic arthritis (SJIA) is an autoinflammatory disease associated with chronic arthritis. Early diagnosis and effective therapy of SJIA is desirable, so that complications are avoided. The PRO-KIND initiative of the German Society for Pediatric Rheumatology (GKJR) aims to define consensus-based strategies to harmonize diagnostic and therapeutic approaches in Germany. METHODS We analyzed data on patients diagnosed with SJIA from 3 national registries in Germany. Subsequently, via online surveys and teleconferences among pediatric rheumatologists with a special expertise in the treatment of SJIA, we identified current diagnostic and treatment approaches in Germany. Those were harmonized via the formulation of statements and, supported by findings from a literature search. Finally, an in-person consensus conference using nominal group technique was held to further modify and consent the statements. RESULTS Up to 50% of patients diagnosed with SJIA in Germany do not fulfill the International League of Associations for Rheumatology (ILAR) classification criteria, mostly due to the absence of chronic arthritis. Our findings suggest that chronic arthritis is not obligatory for the diagnosis and treatment of SJIA, allowing a diagnosis of probable SJIA. Malignant, infectious and hereditary autoinflammatory diseases should be considered before rendering a diagnosis of probable SJIA. There is substantial variability in the initial treatment of SJIA. Based on registry data, most patients initially receive systemic glucocorticoids, however, increasingly substituted or accompanied by biological agents, i.e. interleukin (IL)-1 and IL-6 blockade (up to 27.2% of patients). We identified preferred initial therapies for probable and definitive SJIA, including step-up patterns and treatment targets for the short-term (resolution of fever, decrease in C-reactive protein by 50% within 7 days), the mid-term (improvement in physician global and active joint count by at least 50% or a JADAS-10 score of maximally 5.4 within 4 weeks) and the long-term (glucocorticoid-free clinically inactive disease within 6 to 12 months), and an explicit treat-to-target strategy. CONCLUSIONS We developed consensus-based strategies regarding the diagnosis and treatment of probable or definitive SJIA in Germany.
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Affiliation(s)
- Claas H. Hinze
- 0000 0004 0551 4246grid.16149.3bDepartment of Pediatric Rheumatology and Immunology, University Hospital Münster, Münster, Albert-Schweitzer-Campus 1, Building W30, 48149 Münster, Germany
| | - Dirk Holzinger
- 0000 0004 0551 4246grid.16149.3bDepartment of Pediatric Rheumatology and Immunology, University Hospital Münster, Münster, Albert-Schweitzer-Campus 1, Building W30, 48149 Münster, Germany ,0000 0001 2187 5445grid.5718.bDepartment of Pediatric Hematology-Oncology, University of Duisburg-Essen, Essen, Germany
| | - Elke Lainka
- 0000 0001 0262 7331grid.410718.bDepartment of Pediatrics, University Hospital Essen, Essen, Germany
| | - Johannes-Peter Haas
- German Center for Pediatric and Adolescent Rheumatology, Garmisch-Partenkirchen, Germany
| | - Fabian Speth
- German Center for Pediatric and Adolescent Rheumatology, Garmisch-Partenkirchen, Germany
| | - Tilmann Kallinich
- 0000 0001 2218 4662grid.6363.0Department of Pediatric Pulmonology and Immunology, Charité, Berlin, Germany
| | - Nikolaus Rieber
- Department of Pediatrics, StKM GmbH and Technical University Muenchen, Munich, Germany ,0000 0001 2190 1447grid.10392.39The Department of Pediatrics I, University of Tuebingen, Tuebingen, Germany
| | - Markus Hufnagel
- 0000 0000 9428 7911grid.7708.8Department of Pediatrics, University Hospital Freiburg, Freiburg, Germany
| | - Annette F. Jansson
- 0000 0004 0477 2585grid.411095.8Division of Pediatric Rheumatology & Immunology, Dr. von Hauner Children’s Hospital, University Hospital Munich, Munich, Germany
| | - Christian Hedrich
- 0000 0001 1091 2917grid.412282.fDepartment of Pediatrics, University Hospital Dresden, Dresden, Germany ,0000 0004 1936 8470grid.10025.36Department of Women’s & Children’s Health, Institute of Translational Medicine, University of Liverpool, Liverpool, UK ,0000 0004 0421 1374grid.417858.7Department of Paediatric Rheumatology, Alder Hey Children’s NHS Foundation Trust Hospital, Liverpool, UK
| | - Hanna Winowski
- grid.416438.cDepartment of Pediatric Rheumatology, St. Josef Hospital, Sendenhorst, Germany
| | | | - Ivan Foeldvari
- Hamburg Center for Pediatric and Adolescent Rheumatology, Hamburg, Germany
| | - Gerd Ganser
- grid.416438.cDepartment of Pediatric Rheumatology, St. Josef Hospital, Sendenhorst, Germany
| | - Anton Hospach
- Department of Pediatrics, Olga Hospital, Stuttgart, Germany
| | - Hans-Iko Huppertz
- Department of Pediatrics, Prof. Hess Children’s Hospital, Bremen, Germany
| | | | - Ulrich Neudorf
- 0000 0001 0262 7331grid.410718.bDepartment of Pediatrics, University Hospital Essen, Essen, Germany
| | | | - Helmut Wittkowski
- 0000 0004 0551 4246grid.16149.3bDepartment of Pediatric Rheumatology and Immunology, University Hospital Münster, Münster, Albert-Schweitzer-Campus 1, Building W30, 48149 Münster, Germany
| | - Gerd Horneff
- Department of Pediatrics, Asklepios Hospital, St. Augustin, Germany ,0000 0000 8580 3777grid.6190.eUniversity of Cologne, Cologne, Germany
| | - Dirk Foell
- 0000 0004 0551 4246grid.16149.3bDepartment of Pediatric Rheumatology and Immunology, University Hospital Münster, Münster, Albert-Schweitzer-Campus 1, Building W30, 48149 Münster, Germany
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Fonseca MB, Gomes FHR, Valera ET, Pileggi GS, Gonfiantini PB, Gonfiantini MB, Ferriani VPL, Carvalho LMD. Signs and symptoms of rheumatic diseases as first manifestation of pediatric cancer: diagnosis and prognosis implications. REVISTA BRASILEIRA DE REUMATOLOGIA 2017; 57:330-337. [PMID: 28743360 DOI: 10.1016/j.rbre.2017.01.007] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2016] [Accepted: 11/08/2016] [Indexed: 02/02/2023] Open
Abstract
OBJECTIVE To assess the prevalence and describe the clinical, laboratory and radiological findings, treatment and outcome of children with cancer initially referred to a tertiary outpatient pediatric rheumatology clinic. METHODS Retrospective analysis of medical records from patients identified in a list of 250 new patients attending the tertiary Pediatric Rheumatology Clinic, Ribeirão Preto Medical School hospital, University of São Paulo, from July 2013 to July 2015, whose final diagnosis was cancer. RESULTS Of 250 patients seen during the study period, 5 (2%) had a cancer diagnosis. Among them, 80% had constitutional symptoms, especially weight loss and asthenia, and 60% had arthritis. Initially, all patients had at least one alteration in their blood count, lactate dehydrogenase was increased in 80% and a bone marrow smear was conclusive in 60% of patients. Bone and intestine biopsies were necessary for the diagnosis in 2 patients. JIA was the most common initial diagnosis. The definitive diagnosis was acute lymphoblastic leukemia (2 patients), M3 acute myeloid leukemia, lymphoma, and neuroblastoma (one case each). Of 5 patients studied, 3 (60%) are in remission and 2 (40%) died, one of them with prior use of steroids. CONCLUSION The constitutional and musculoskeletal symptoms common to rheumatic and neoplastic diseases can delay the diagnosis and consequently worsen the prognosis of neoplasms. Initial blood count and bone marrow smear may be normal in the initial framework of neoplasms. Thus, the clinical follow-up of these cases becomes imperative and the treatment, mainly with corticosteroids, should be delayed until diagnostic definition.
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Affiliation(s)
- Mariana Bertoldi Fonseca
- Universidade de São Paulo (USP), Faculdade de Medicina de Ribeirão Preto (FMRP), Hospital das Clínicas, Ribeirão Preto, SP, Brazil
| | - Francisco Hugo Rodrigues Gomes
- Universidade de São Paulo (USP), Faculdade de Medicina de Ribeirão Preto (FMRP), Hospital das Clínicas, Ribeirão Preto, SP, Brazil
| | - Elvis Terci Valera
- Universidade de São Paulo (USP), Faculdade de Medicina de Ribeirão Preto (FMRP), Hospital das Clínicas, Ribeirão Preto, SP, Brazil
| | - Gecilmara Salviato Pileggi
- Universidade de São Paulo (USP), Faculdade de Medicina de Ribeirão Preto (FMRP), Hospital das Clínicas, Ribeirão Preto, SP, Brazil
| | - Paula Braga Gonfiantini
- Universidade de São Paulo (USP), Faculdade de Medicina de Ribeirão Preto (FMRP), Ribeirão Preto, SP, Brazil
| | - Marcela Braga Gonfiantini
- Universidade de São Paulo (USP), Faculdade de Medicina de Ribeirão Preto (FMRP), Ribeirão Preto, SP, Brazil
| | | | - Luciana Martins de Carvalho
- Universidade de São Paulo (USP), Faculdade de Medicina de Ribeirão Preto (FMRP), Hospital das Clínicas, Ribeirão Preto, SP, Brazil.
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Sinais e sintomas sugestivos de doenças reumáticas como primeira manifestação de doenças neoplásicas na infância: implicações no diagnóstico e prognóstico. REVISTA BRASILEIRA DE REUMATOLOGIA 2017. [DOI: 10.1016/j.rbr.2016.11.001] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023] Open
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21
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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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22
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Kang S, Im HJ, Bae K, Park SS. Influence of Musculoskeletal Manifestations as the Only Presenting Symptom in B-Cell Acute Lymphoblastic Leukemia. J Pediatr 2017; 182:290-295.e1. [PMID: 28063690 DOI: 10.1016/j.jpeds.2016.11.072] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/17/2016] [Revised: 10/14/2016] [Accepted: 11/28/2016] [Indexed: 01/17/2023]
Abstract
OBJECTIVE To evaluate the clinical and prognostic impact of musculoskeletal manifestations as the only initial presenting symptom in childhood acute lymphoblastic leukemia (ALL). STUDY DESIGN We retrospectively reviewed 158 children with precursor B-cell type ALL who were followed up for >2 years. The patients were assigned to the groups musculoskeletal manifestations (n = 24) or nonmusculoskeletal manifestations (n = 134) based on initial presenting symptom. The symptom duration (regarding any initial presenting symptom) and the leukemic symptom duration (regarding symptoms of systemic manifestation, such as fever, bleeding, or pallor) were assessed, along with other clinical characteristics. RESULTS The musculoskeletal manifestations group exhibited a longer symptom duration than the nonmusculoskeletal manifestations group (43 days vs 22 days, P = .006), but overall survival did not significantly differ between the groups. Multivariate analysis indicated that a longer symptom duration did not affect prognosis but that a longer leukemic symptom duration was associated with a poorer prognosis (hazard ratio, 7.720; P = .048). CONCLUSION Musculoskeletal manifestations are associated significantly with diagnostic delay, but this delay does not affect the prognosis. Diagnostic delay after the onset of leukemic symptoms, however, does appear to affect the prognosis. Intensive evaluations for hematologic malignancies may be unnecessary in children who complain of limb pain without any definite cause, unless they also present with accompanying leukemic symptoms.
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Affiliation(s)
- Seungcheol Kang
- Department of Orthopedic Surgery, Asan Medical Center Children's Hospital, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Ho Joon Im
- Department of Pediatrics, Division of Pediatric Hematology/Oncology, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Kunhyung Bae
- Department of Orthopedic Surgery, Asan Medical Center Children's Hospital, University of Ulsan College of Medicine, Seoul, Republic of Korea
| | - Soo-Sung Park
- Department of Orthopedic Surgery, Asan Medical Center Children's Hospital, University of Ulsan College of Medicine, Seoul, Republic of Korea.
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23
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Suter B, Jones Y. The Curious Case of the Limping Toddler. Clin Pediatr (Phila) 2016; 55:574-6. [PMID: 26239919 DOI: 10.1177/0009922815598862] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Affiliation(s)
- Blair Suter
- West Virginia University School of Medicine, Morgantown, WV, USA
| | - Yemisi Jones
- University of Cincinnati College of Medicine, Oh, USA
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24
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Cattalini M, Parissenti I, Tononcelli E, Lancini F, Cantarini L, Meini A. Developing a Predictive Score for Chronic Arthritis among a Cohort of Children with Musculoskeletal Complaints--The Chronic Arthritis Score Study. J Pediatr 2016; 169:188-93. [PMID: 26616250 DOI: 10.1016/j.jpeds.2015.10.081] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/26/2015] [Revised: 10/12/2015] [Accepted: 10/26/2015] [Indexed: 11/27/2022]
Abstract
OBJECTIVE To explore if features obtained from a carefully taken medical history can be predictors of the final diagnosis in children with musculoskeletal complaints. STUDY DESIGN We collected detailed clinical information on 178 children referred to our Pediatric Immunology and Rheumatology Unit by their primary care pediatrician for musculoskeletal complaints; a univariate logistic analysis was performed to identify variables correlated with the diagnosis of chronic arthritis. The variables identified were combined in a linear score that indicates the probability for a patient with musculoskeletal pain to receive the diagnosis of chronic arthritis. RESULTS The joint swelling pattern (P < .0001), the precipitating factors of pain (P = .001), the duration of morning stiffness (P < .0001) and the frequency of pain (P < .0001), were found to be independently correlated with the diagnosis of chronic arthritis and were used to develop a diagnostic score. This score had a sensitivity of 90.9% and specificity of 95.3%. CONCLUSIONS We developed a score that could be useful in the daily clinical routine to correctly direct the differential diagnosis in a child with musculoskeletal complaints, rationalizing time and resources necessary to reach a definitive diagnosis.
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Affiliation(s)
- Marco Cattalini
- Pediatric Clinic, University of Brescia and Spedali Civili di Brescia, Brescia, Italy.
| | - Ilaria Parissenti
- Pediatric Clinic, University of Brescia and Spedali Civili di Brescia, Brescia, Italy
| | - Elena Tononcelli
- Pediatric Clinic, University of Brescia and Spedali Civili di Brescia, Brescia, Italy
| | - Francesca Lancini
- Physiatry Unit, University of Brescia and Spedali Civili di Brescia, Brescia, Italy
| | - Luca Cantarini
- Research Center of Systemic Autoimmune and Autoinflammatory Diseases and Behcet's Disease Clinic, Rheumatology Unit, Policlinico Le Scotte, University of Siena, Siena, Italy
| | - Antonella Meini
- Pediatric Clinic, University of Brescia and Spedali Civili di Brescia, Brescia, Italy
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Affiliation(s)
- Ethan S Sen
- Department of Paediatric Rheumatology, Bristol Royal Hospital for Children, Bristol, UK
| | - John P Moppett
- Department of Paediatric Haematology and Oncology, Bristol Royal Hospital for Children, Bristol, UK
| | - A V Ramanan
- Department of Paediatric Rheumatology, Bristol Royal Hospital for Children, Bristol, UK
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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
Monoarthritis, defined as inflammation of a single joint, requires a thorough physical examination in children, as pain may be lacking in 10% to 30% of cases and joint stiffness may be the only symptom. Joint aspiration is a crucial diagnostic tool that remains markedly underused. Joint aspiration may be unnecessary, however, when the family history or other investigations provide the diagnosis. Radiographs of the involved joint may supply information on the severity of the lesions. In doubtful cases and in patients with arthralgia, B-mode and Doppler ultrasound or magnetic resonance imaging (MRI) may confirm the presence of synovitis. Although suspected septic arthritis is an emergency and occurs frequently, particularly before 2 years of age, acute monoarthritis is often a post-infectious manifestation and therefore associated with a good outcome. Lyme disease should be sought, particularly when a lower limb joint is involved, as tick bites often go unnoticed. Chronic monoarthritis is very often a manifestation of juvenile idiopathic arthritis (JIA), which exists as several variants. Oligoarthritis is a specifically pediatric joint disease, whereas the other patterns of JIA have corresponding forms in adults, despite a number of specific features due to their onset during childhood. Tests for antinuclear antibodies should be performed routinely in children with monoarthritis persisting longer than 3 weeks. A decline in general health or a fever should suggest arthritis revealing a malignancy, which is a hematological disease in most cases. Finally, suggestive symptoms are often present in patients with less common causes such as auto-inflammatory diseases and connective tissue diseases.
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Spencer CH, Patwardhan A. Pediatric Rheumatology for the Primary Care Clinicians-Recognizing Patterns of Disease. Curr Probl Pediatr Adolesc Health Care 2015. [PMID: 26205101 DOI: 10.1016/j.cppeds.2015.04.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
This review presents a diagnostic approach to musculoskeletal and rheumatic diseases in children for primary care clinicians. The focus is on juvenile idiopathic arthritis (JIA) as the major arthritis disease in children. It is necessary to know the personalities of these JIA categories. It is also crucial to be able to recognize the common infectious, orthopedic and mechanical, malignant, genetic, other rheumatic diseases, and other miscellaneous syndromes that can mimic JIA. To do so requires recognition of clinical patterns using a thorough musculoskeletal and rheumatic history and repeated complete physical exams with emphasis on the musculoskeletal exam. It also requires targeted and limited laboratory testing with careful follow-up over time.
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29
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Rationale Diagnostik der juvenilen idiopathischen Arthritis. Monatsschr Kinderheilkd 2015. [DOI: 10.1007/s00112-014-3279-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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30
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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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Yi JH, Wang D, Li ZY, Hu J, Niu XF, Liu XL. C-reactive protein as a prognostic factor for human osteosarcoma: a meta-analysis and literature review. PLoS One 2014; 9:e94632. [PMID: 24800842 PMCID: PMC4011684 DOI: 10.1371/journal.pone.0094632] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2013] [Accepted: 03/19/2014] [Indexed: 12/12/2022] Open
Abstract
Background Osteosarcoma is the most common primary bone cancer in growing adolescents and young adults. The prognostic role of C-reactive protein (CRP) in patients with osteosarcoma is not fully investigated. The purpose of this study is to perform a meta-analysis and literature review on the role of CRP in osteosarcoma and to assess the potential role of serum CRP as a prognostic factor for patients with osteosarcoma. Methods A detailed literature search was made in Medline for related research publications written in English. Methodological quality of the studies was also evaluated. The data were extracted and assessed by two reviewers independently. Analysis of pooled data were performed, risk ratio (RR) and corresponding confidence intervals (CIs) were calculated and summarized respectively. Results Final analysis of 397 patients from 2 eligible studies was performed. Combined RR of CRP expression suggested that the raised serum CRP level had an adverse prognostic effect on overall survival of patients with osteosarcoma (n = 397 in 2 studies; RR = 0.35; 95% CI: 0.18–0.68; p = 0.002). In the uni- and multivariate survival analysis, response rate and CRP levels were the only independent prognostic variables. Conclusions The results of this meta-analysis suggest that CRP expression confers a worse prognosis in patients with osteosarcoma. Large prospective studies are necessary to provide solid data to confirm the prognostic significance of CRP.
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Affiliation(s)
- Jian-Hua Yi
- The Upper Limb Orthopedic Department of Huang Pu Award, The First Affiliated Hospital of Sun Yat-Sen University Guangzhou, China
| | - Dong Wang
- The Upper Limb Orthopedic Department of Huang Pu Award, The First Affiliated Hospital of Sun Yat-Sen University Guangzhou, China
| | - Zhi-Yong Li
- The Upper Limb Orthopedic Department of Huang Pu Award, The First Affiliated Hospital of Sun Yat-Sen University Guangzhou, China
- * E-mail:
| | - Jun Hu
- The Upper Limb Orthopedic Department of Huang Pu Award, The First Affiliated Hospital of Sun Yat-Sen University Guangzhou, China
| | - Xiao-Feng Niu
- The Upper Limb Orthopedic Department of Huang Pu Award, The First Affiliated Hospital of Sun Yat-Sen University Guangzhou, China
| | - Xiao-Lin Liu
- The Upper Limb Orthopedic Department of Huang Pu Award, The First Affiliated Hospital of Sun Yat-Sen University Guangzhou, China
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Zombori L, Kovacs G, Csoka M, Derfalvi B. Rheumatic symptoms in childhood leukaemia and lymphoma-a ten-year retrospective study. Pediatr Rheumatol Online J 2013; 11:20. [PMID: 23641776 PMCID: PMC3645950 DOI: 10.1186/1546-0096-11-20] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/28/2012] [Accepted: 04/26/2013] [Indexed: 11/11/2022] Open
Abstract
BACKGROUND The initial symptoms of childhood leukaemia and lymphoma are often similar to those of juvenile idiopathic arthritis (JIA). In our study, we analyzed the frequency and characteristics of musculoskeletal complaints as the initial presenting symptoms of newly diagnosed leukaemia and lymphoma patients in the past 10 years in our clinic. METHODS Using the Hungarian Tumour Register, we performed a retrospective analysis of the medical records of 166 new leukaemia and 95 new lymphoma pediatric patients treated from 1999 to 2009 at the 2nd. Dept. of Paediatrics of the Semmelweis University in Budapest. RESULTS Twenty percent of the leukaemic (33 children) and 2% of the lymphoma patients (2 children) had musculoskeletal symptoms at first presentation. Two-thirds of both groups of patients had other general symptoms like fever and/or fatigue. The hip was the most frequently affected joint (7/33) in the leukaemic patients. Twenty-four percent of all the children had been previously evaluated by an orthopaedist; 12% had visited another rheumatologist prior to diagnosis. Imaging had been done in an unexpectedly low number of patients prior to referral to our unit (radiographs: 16 or 48%, ultrasound: 5 patients or 15%). Radiographs of the affected joints were abnormal in only one case (1/16, 6%). The joint ultrasound was abnormal in only three children of 5 studied (3/5, 60%). Anaemia (26/32, 6%), thrombocytopenia (78%) and LDH elevation (3-4 times the normal count) were frequent in the leukaemic patients. Half of the cases had a normal leukocyte count. The lymphoma group had similar results. Two patients of the leukaemia group received steroid treatment before the final diagnosis. Severe pain out of proportion to physical findings is another clue. CONCLUSIONS Haematologic malignancies must be excluded before initiation of therapy for childhood arthritis among children presenting with musculoskeletal signs and symptoms, particularly in atypical cases. Malignancies are to be suspected when pain is disproportionately severe compared to the physical examination findings, and when anaemia, thrombocytopenia, and an elevated LDH level are present. Diagnosing leukaemia early is important because the use of steroids and immunosuppressive medications may mask and delay its diagnosis. Additionally, pre-treatment of presumed JIA patients with these drugs who eventually are diagnosed to have a malignancy may lead to the malignancy being steroid-resistant and more difficult to treat.
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Affiliation(s)
- Luca Zombori
- 2nd Department of Paediatrics, Semmelweis University Budapest, 1094, Tuzolto u 7-9, Budapest, Hungary
| | - Gabor Kovacs
- 2nd Department of Paediatrics, Semmelweis University Budapest, 1094, Tuzolto u 7-9, Budapest, Hungary
| | - Monika Csoka
- 2nd Department of Paediatrics, Semmelweis University Budapest, 1094, Tuzolto u 7-9, Budapest, Hungary
| | - Beata Derfalvi
- 2nd Department of Paediatrics, Semmelweis University Budapest, 1094, Tuzolto u 7-9, Budapest, Hungary
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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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[Definition, diagnosis and therapy of chronic widespread pain and so-called fibromyalgia syndrome in children and adolescents. Systematic literature review and guideline]. Schmerz 2013; 26:318-30. [PMID: 22760465 DOI: 10.1007/s00482-012-1168-y] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
BACKGROUND The scheduled update to the German S3 guidelines on fibromyalgia syndrome (FMS) by the Association of the Scientific Medical Societies ("Arbeitsgemeinschaft der Wissenschaftlichen Medizinischen Fachgesellschaften", AWMF; registration number 041/004) was planned starting in March 2011. MATERIALS AND METHODS The development of the guidelines was coordinated by the German Interdisciplinary Association for Pain Therapy ("Deutsche Interdisziplinären Vereinigung für Schmerztherapie", DIVS), 9 scientific medical societies and 2 patient self-help organizations. Eight working groups with a total of 50 members were evenly balanced in terms of gender, medical field, potential conflicts of interest and hierarchical position in the medical and scientific fields. Literature searches were performed using the Medline, PsycInfo, Scopus and Cochrane Library databases (until December 2010). The grading of the strength of the evidence followed the scheme of the Oxford Centre for Evidence-Based Medicine. The formulation and grading of recommendations was accomplished using a multi-step, formal consensus process. The guidelines were reviewed by the boards of the participating scientific medical societies. RESULTS AND CONCLUSION The diagnosis FMS in children and adolescents is not established. In so-called juvenile FMS (JFMS) multidimensional diagnostics with validated measures should be performed. Multimodal therapy is warranted. In the case of severe pain-related disability, therapy should be primarily performed on an inpatient basis. The English full-text version of this article is available at SpringerLink (under "Supplemental").
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Abstract
Musculoskeletal pain is one of the most common presenting symptoms at the pediatrician's office. Etiology ranges from benign conditions to serious ones requiring prompt attention. This article addresses entities that present as musculoskeletal pain but are not associated with arthritis. The most common nonarthritic conditions are benign limb pain of childhood (growing pains), hypermobility, overuse syndromes with or without skeletal abnormalities, malignancies, and pain amplification syndromes. The| initial decision process, diagnosis, and treatment options for each of these conditions are discussed.
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Affiliation(s)
- Peter Weiser
- Division of Pediatric Rheumatology, Department of Pediatrics, Children's of Alabama, University of Alabama at Birmingham, Birmingham, AL 35233, USA.
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Teo WY, Chan MY, Ng KC, Tan AM. Bony presentations of childhood haematological malignancy to the emergency room. J Paediatr Child Health 2012; 48:311-6. [PMID: 22077629 DOI: 10.1111/j.1440-1754.2011.02230.x] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Abstract
AIM Bony complaints are well-recognised symptoms of childhood haematological malignancy. However, this elusive symptom complex of haematological malignancy is not easily recognised in the emergency room (ER) where musculoskeletal problems are frequent. This study reviews bony complaints of childhood haematological malignancy in the ER. METHODS This was a retrospective study of 148 children diagnosed with haematological malignancy between March 2002 and February 2007. RESULTS Twenty-one cases (14.2%) presented with bony complaints to the ER within 3 months prior diagnosis of malignancy. The median age was 5.1 years, and majority (90.5%) had acute lymphoblastic leukaemia. Fifteen cases were undiagnosed for malignancy at first visit; diagnoses included pulled elbow, lower limb sprain and septic arthritis, with 21 days median time to correct diagnosis. In this undiagnosed group, history of trauma, fever, multiple bony site involvement, normal radiography and blood counts were common. Undiagnosed cases were referred to orthopaedics, paediatrics, rheumatology or the general practitioner, hospitalised or discharged without follow-up. CONCLUSION The diagnosis of childhood haematological malignancy with first bony presentation to the ER was challenging, with a high prevalence of 71.4% undiagnosed cases at first visit. We highlight the common misdiagnoses because failure to correctly diagnose could delay timely institution of treatment. Trauma or normal investigations do not exclude an underlying haematological malignancy. This rare diagnosis in the ER should always be considered when challenged with recurrent bony complaints.
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Affiliation(s)
- Wan-Yee Teo
- Department of Paediatric Medicine, Haematology Oncology Service, KK Women's and Children's Hospital, Singapore.
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Shiner EK, McLean T, Pang CS, Rouster-Stevens K. A 9-year-old girl with ankle, knee, and shoulder pain. Arthritis Care Res (Hoboken) 2012; 64:149-56. [PMID: 22213728 DOI: 10.1002/acr.20606] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Affiliation(s)
- Erin K Shiner
- Wake Forest School of Medicine, Winston-Salem, North Carolina 27157, USA
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Waimann CA, Lu H, Suarez Almazor ME. Rheumatic manifestations of primary and metastatic bone tumors and paraneoplastic bone disease. Rheum Dis Clin North Am 2011; 37:527-49. [PMID: 22075196 DOI: 10.1016/j.rdc.2011.09.009] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023]
Abstract
Bone tumors can show a wide range of nonspecific rheumatic manifestations. The presence of unexplained or atypical chronic bone pain, an enlarging bone mass, neurovascular compression syndromes, or pathologic fractures should alert us to the possibility of a bone tumor causing these symptoms. These patients must undergo a complete physical examination; adequate imaging; and, if needed, a biopsy to confirm their diagnosis and offer them an opportune treatment. In addition, bone tumors and other malignancies can present remote clinical manifestations and unusual laboratory findings (eg, HOA, hypophosphatemia, hyperphosphaturia, and hypercalcemia) that may be the first and early manifestation of an occult cancer. These findings should motivate a cancer screening according to age, sex, and personal history. Cancer therapies also have a big impact on bone health, increasing the risk of osteoporosis, osteomalacia, and/or osteonecrosis. Rheumatologists should be aware of possible long-term adverse events of cancer treatment to avoid future complications.
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Affiliation(s)
- Christian A Waimann
- Section of Rheumatology, Department of General Internal Medicine, The University of Texas at MD Anderson Cancer Center, 1515 Holcombe Boulevard, Unit 1465, Houston, TX 77030, USA.
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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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Abstract
Juvenile idiopathic arthritis, formerly known as juvenile rheumatoid arthritis, is a heterogeneous group of diseases characterized by onset of chronic arthritis in childhood. Diagnosis requires onset of disease by age 16 years, persistent arthritis in any joint for ≥ 6 weeks, and exclusion of other conditions that cause arthritis (eg, infection, malignancy, acute rheumatic fever, inflammatory bowel disease). Most patients with juvenile idiopathic arthritis present with subacute arthritis with minimal pain and few constitutional symptoms. Laboratory evaluation and imaging are useful to exclude other diagnoses and establish the presence of systemic inflammation. However, these modalities are of limited value in screening for rheumatic diseases, and they may be misleading because of the high rate of false-positive results. Most rheumatologic conditions are diagnosed based on pattern recognition, which is established with a thorough history and physical examination.
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Horneff G, Foeldvari I, Minden K, Moebius D, Hospach T. Report on malignancies in the German juvenile idiopathic arthritis registry. Rheumatology (Oxford) 2010; 50:230-6. [PMID: 21148157 DOI: 10.1093/rheumatology/keq361] [Citation(s) in RCA: 47] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Affiliation(s)
- Gerd Horneff
- Department of Pediatrics, Asklepios Clinic Sankt Augustin, Arnold-Jannssen Str. 29, 53757 Sankt Augustin, Germany.
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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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McKay D, Adams L, Ostring G, Singh-Grewal D. In a child presenting with features consistent with a diagnosis of juvenile idiopathic arthritis, what clinical features or laboratory findings (at presentation) predict a diagnosis of acute lymphoblastic leukaemia? J Paediatr Child Health 2010; 46:442-5. [PMID: 20649859 DOI: 10.1111/j.1440-1754.2010.01807.x] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
- Damien McKay
- Department of Rheumatology, The Children's Hospital at Westmead, Sydney, New South Wales, Australia
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Horneff G. Malignome und Tumor-Nekrose-Faktor-Inhibitoren bei der juvenilen idiopathischen Arthritis. Z Rheumatol 2010; 69:516-26. [DOI: 10.1007/s00393-010-0655-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
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Casado Picón R, Barrios López M, de Inocencio Arocena J, Baro Fernández M, Vivanco Martínez JL. [Musculoskeletal pain: a common initial sign of acute lymphoblastic leukaemia]. An Pediatr (Barc) 2010; 72:428-31. [PMID: 20417164 DOI: 10.1016/j.anpedi.2010.01.014] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/21/2009] [Revised: 11/24/2009] [Accepted: 01/18/2010] [Indexed: 10/19/2022] Open
Abstract
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.
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Affiliation(s)
- R Casado Picón
- Sección de Reumatología Infantil, Servicio de Pediatría, Hospital Doce de Octubre, Madrid, España.
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Abstract
Childhood cancer is uncommon but remains the leading cause of disease-related death in children. Symptoms are often vague or insidious; they may suggest a more common alternative diagnosis, and they are quite different from those associated with adult malignancy. The skilled office practitioner must consider cancer as a diagnosis when symptoms/signs persist or when multiple symptoms point toward a possible diagnosis of malignancy. Early diagnosis is critical, as survival rates have increased dramatically over the past decades. Prolonged delay in diagnosis is common, especially for brain tumors and certain lymphomas (Hodgkin disease). When one encounters symptoms suspicious for a childhood malignancy, it is imperative that the child be referred to a pediatric cancer center. These centers possess not only the ability to further evaluate and manage children with malignancy, but also are able to provide support for patients and their families. This evaluation may include further imaging, but often involves obtaining tissue for histologic review. This will require appropriate tumor or bone marrow biopsy, preferably before the start of treatment. Depending upon the type of suspected malignancy, direct tumor biopsy can be facilitated by imaging-guided biopsy (ultrasound, CT, or MRI), which spares the patient additional surgery. This optimally is performed by a skilled team: hematologist/oncologist, surgeon, radiologist, and pathologist. Best results depend upon early referral by the thoughtful practitioner.
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Affiliation(s)
- Christopher P Raab
- Department of Pediatrics, Thomas Jefferson University, Philadelphia, PA, USA.
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Abstract
The presence of an intra-articular knee effusion requires an extensive differential diagnosis and a systematic diagnostic approach. Pediatric knee effusions occur most commonly as acute hemarthroses after traumatic injury. However, the knee joint is susceptible to effusions secondary to a wide variety of atraumatic causes. Special attention is required in the atraumatic effusion to distinguish features of infectious, postinfectious, rheumatologic, hematologic, vasculitic, and malignant disease. This review discusses the various etiologies of both traumatic and atraumatic pediatric knee effusions highlighting the historical, physical examination, and laboratory characteristics to aid the emergency provider in diagnosis and initial management.
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Marwaha RK, Kulkarni KP, Bansal D, Trehan A. Acute lymphoblastic leukemia masquerading as juvenile rheumatoid arthritis: diagnostic pitfall and association with survival. Ann Hematol 2009; 89:249-54. [PMID: 19727722 DOI: 10.1007/s00277-009-0826-3] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2009] [Accepted: 08/20/2009] [Indexed: 10/20/2022]
Abstract
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.
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Affiliation(s)
- Ram Kumar Marwaha
- Division of Pediatric Hematology-Oncology, Advanced Pediatric Center, PGIMER, Sec 12, Pin: 160012, Chandigarh, India.
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Predictive plain X-ray findings in distinguishing early stage acute lymphoblastic leukemia from juvenile idiopathic arthritis. Clin Rheumatol 2009; 28:1253-8. [DOI: 10.1007/s10067-009-1221-0] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2008] [Revised: 05/25/2009] [Accepted: 06/14/2009] [Indexed: 10/20/2022]
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50
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Onkologische Ursachen von Knochenschmerzen. Monatsschr Kinderheilkd 2009. [DOI: 10.1007/s00112-009-1962-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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