A case of Leukemia.
Dr.Akshay Kishore , Dr.Suma Balan , Dr.C.Jayakumar
Five year old male child presented with joint swelling and redness of 1 month duration
To begin with pain and swelling occurred in small joints of hand and then to elbow and foot associated severe bone pain especially in the limbs. There is history of night cry and awakening due to pain. There was history of fever since the onset of the symptom but with outrash any type. Early morning stiffness /oral ulcers/genital ulcers/breathlessness were absent.
There is no significant past history of similar problems or gastrointestinal intestinal disorder for the child. He had received steroids from outside but there was no improvement in symptoms.
Differential diagnosis considered at this point were-
1.Polyarticular rheumatoid arthritis
2Rheumatic fever
3Poststreptococcal reactive arthritis
4.Arthritis following gram negative GI disorder
5. Haematological malignancy
• Picture showing swelling of fingers.
On examination : no pallor jaundice or lymphadenopathy.
Bilateral swelling in the right ring finger between Distal interphalangeal joint and proximal interphalangeal joint with tenderness was noted
Bilateral ankle swelling with tenderness prevented him from walking
Severe bony tenderness was noted all over the upper limb and lower limb.
Labs
CRP -106mg/L
◦ CBC normal
LDH – 362U/L and ferritin 354ng/ml- both were elevated.
Peripheral smear done on admission was normal
Pre op serology was negative.
X-ray wrist and ankle was taken which was normal.
USG abdomen showed borderline hepatomegaly with splenomegaly.
He was started on Naproxen at 20mg/kg/day after which the pain improved.
Whole body FDG PET MR showed abnormal generalised increased FDG uptake in marrow of entire axial and appendicular skeleton. Focal FDG activity in distal end of left ulna and bilateral fibular shafts.
Peripheral smear was tested and that showed – acute leukemia with blast 21%.
• Arrow showing cells with large nuclei showing blast cells.
Bone marrow study was consistent with acute B-cell leukemia. He is planned for chemotherapy.
Discussion- Bone pain can occur in leukemia patients when the bone marrow expands from accumulation of abnormal white blood cells and may manifest as a sharp pain or dull pain. Bone pain is one of the very important presenting features of acute leukemia.
Carry home message: Leukemia should be strongly suspected in patients with limping and unexplained pain over any bones and peripheral smear and in most of the cases Bone marrow examination is mandatory