For physicians, diagnosing hematologic malignancies in children can often be challenging. The clinical signs and symptoms can often be non-specific or mimic other disease processes. We present the case of a previously healthy pediatric patient with persistent back and abdominal pain whose ultimate diagnosis of Hodgkin Lymphoma mimicked the osteomyelitis. As this case illustrates, it is imperative to be persistent and maintain a broad differential diagnosis in children during their evaluation and treatment stages in order to make the correct diagnosis.Keywords: Hematologic malignancies; Hodgkin lymphoma; Osteomyelitis; Abdominal pain Case ReportA previously healthy 12-year-old male presented to the emergency department where he was evaluated for 6-7 weeks of low back pain and one week of diffuse, cramping right lower quadrant abdominal pain. The patient was an active 7 th grader who played tennis and basketball and thus thought that his back pain may be musculoskeletal in nature. He had noticed slight improvement of his back pain with Advil; however, his abdominal pain had been worsening over the past week. His parents reported that he "hadn't looked right" for a few weeks. His review of systems was negative for fever, urologic complaints, cough, shortness of breath, chest pain, testicular pain, trauma, recent travel or exposure to homeless or prison populations. The patient has no significant past medical or surgical history, medications, or allergies. He was not sexually active and denied the use of drugs or alcohol. He lived with his mom, dad, and sister. Family history revealed MRSA skin infections in sister associated with school sports.Physical examination revealed stable vital signs without fever, and was significant for a diffusely tender abdomen with increased tenderness in the right and left upper quadrants. There was no rebound, guarding, masses, or organomegaly. The patient also had mild tenderness to palpation over the right lumbar paraspinal muscles but no midline tenderness to palpation. There was no notable lymphadenopathy. Overall he appeared to be a healthy pre-teen in no acute distress.Emergency department evaluation included the following tests. A complete blood count (CBC) revealed a WBC of 11.1 k/ cumm with a normal differential; hemoglobin of 11.2 gm/dL; hematocrit of 34.3%; and platelets of 350 k/cumm. A basic metabolic panel (BMP) and liver function tests were normal. An erythrocyte sedimentation rate (ESR) and C-reactive protein (CRP) were elevated at 76 mm/hr and 3.4 mg/dL, respectively.A Chest X-ray revealed bilateral hilar lymphadenopathy ( Figure 1) with no parenchymal lesions. An abdomen/pelvis with IV contrast showed no signs of acute appendicitis but revealed a destructive lesion of the first lumbar vertebral body (L1) with paraspinal swelling of the adjacent right psoas muscle in addition to multiple microabscesses in the spleen with likely lymphadenopathy near the portal hepatitis.
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