Acute lymphoblastic leukemia: primary bone manifestation with hypercalcemia in a child

An unusual onset of pediatric acute lymphoblastic leukemia

“…The white blood cell count is variable in the initial CBC: it can be increased, reduced, but also be normal; thrombocytopenia and normocytic normochromic anemia are almost always present and the peripheral blood smear may not highlight blasts. The other laboratory investigations usually show nonspecific alterations, such as the increase in LDH and ESR [3,7,8]. In our case, the little girl did not show the typical clinical picture of leukemia.…”

“…Asthenia, pallor and tachycardia are caused by anemia; fever and recurrent or prolonged infections are linked to neutropenia and hemorrhagic manifestations (petechiae, gingivorrhagia, epistaxis) are due to thrombocytopenia [3,5,6]. Compared to T cell ALL (T-ALL), B-ALL is characterized by the tendency to manifest itself at the onset with bone pain which is present in 50% of cases and particularly affects long bones [3,5,7]. In addition, lymphadenomegaly and/or hepatosplenomegaly is often present at diagnosis in children with B-ALL; however, CNS involvement is rare and is more frequent in children with T-ALL [3,6,7].…”

“…Compared to T cell ALL (T-ALL), B-ALL is characterized by the tendency to manifest itself at the onset with bone pain which is present in 50% of cases and particularly affects long bones [3,5,7]. In addition, lymphadenomegaly and/or hepatosplenomegaly is often present at diagnosis in children with B-ALL; however, CNS involvement is rare and is more frequent in children with T-ALL [3,6,7]. The white blood cell count is variable in the initial CBC: it can be increased, reduced, but also be normal; thrombocytopenia and normocytic normochromic anemia are almost always present and the peripheral blood smear may not highlight blasts.…”

“…The ovary is another common extranodal site of BL which makes up 19% of adnexal lymphomas [12,14]. The histological examination of intestinal and ovarian lesions of the little girl identified atypical lymphoid cells of the B line and the most relevant aspect for the diagnosis was the expression of TdT which is a nuclear enzyme recognizable in early lymphoid cells and is absent in mature B lymphocytes of the BL [3,[5][6][7]12]. The histological report indicated a lymphoproliferative process compatible with B-ALL/B-LBL.…”

Hypercalcemia and multiple osteolytic bone lesions: A rare presentation of acute lymphoblastic leukemia

“…Major underlying mechanisms of hypercalcemia of malignancy are increased tumor secretion of Parathyroid Hormone-Related Peptide (PTHrP), osteolytic bone destruction, tumoral production of 1,25 dihydroxy vitamin D and proinflammatory cytokines [Tumor Necrosis Factor-Alpha (TNFα) and Interlukins (IL)] and Production Of Parathyroid Hormone (PTH) [4,5]. Acute Lymphocytic Leukemia (ALL) presenting with hypercalcemia in conjunction with osteolytic bone lesion could be a rare event, however, most of them are characterized in children affected by B-ALL [6][7][8][9]. This condition could be a rare initial manifestation of adult ALL and limited to only some cases reports in the world [10,11].…”