Diagnosis of malignancies in children with musculoskeletal complaints

Abstract

CONTEXT: Musculoskeletal complaints may be associated with neoplasias as an initial manifestation of the disease. When these symptoms predominate at the onset of the disease, the differential diagnosis includes several rheumatic diseases. OBJECTIVE: To assess the frequency, clinical features and types of cancer manifested in children presenting with musculoskeletal complaints over a seven-year period. TYPE OF STUDY: Retrospective. SETTING: Discipline of Allergy, Clinical Immunology and Rheumatology, Universidade Federal de São Paulo - Escola Paulista de Medicina. METHODS: The medical records of patients with musculoskeletal complaints and final diagnosis of malignant disease were reviewed. The data collected were: age when symptoms initially presented, age at diagnosis, clinical features presented, laboratory findings, and the initial and final diagnoses. RESULTS: A final diagnosis of cancer was found in nine out of 3,528 patients (0.25%) whose initial symptom was musculoskeletal pain. The mean time between disease onset and final diagnosis was five months. The most common features presented were pauciarticular arthritis or arthralgia involving the large joints. Juvenile rheumatoid arthritis was the most frequent initial diagnosis, in four out of nine patients. Anemia was the most frequent initial hematological change. Six out of eight patients had an increased erythrocyte sedimentation rate. The lactate dehydrogenase level was raised in five out of eight patients. The malignancies found included acute lymphocytic leukemia, acute myeloid leukemia, lymphoma, neuroblastoma and Ewing's sarcoma. DISCUSSION: The frequency of neoplasia in patients with musculoskeletal pain resembled reports in the literature. Consumptive symptoms were not the warning signal in most of our patients. In subsidiary tests, progressive anemia was the most common finding, although the peripheral blood cell count may continue to be normal for weeks or months after symptom onset. CONCLUSION: Malignancy always needs to be ruled out in cases of children with musculoskeletal complaints. Uncharacteristic clinical manifestations and nonspecific laboratory tests may cause difficulty in the final diagnosis, and rigorous investigation should be performed.

Case of an Acute lymphoblastic Leukemia Presenting as Elbow Septic Arthritis

“…Hastalığın başlangıç bulgularının ortaya çıkması haftalar hatta aylar sürebilir. Bu bulgular nonspesifik olup, ateş yüksekliği, hâlsizlik, solukluk, ekstremite ve eklem ağrılarıdır (1) . ALL ço-cuklarda kemik ve ekstremite ağrılarından çok tek veya çoklu eklem tutulumu ile seyretmektedir (8,9) .…”

“…Çocukluk çağında kas iskelet yakınması malignitelerle ilişkili olup, bu hastalıkların başlangıç bulgusu olabilmektedir (1) . Özellikle akut lösemi çocuklarda ortopedik sorunları taklit ederek kesin tanının geçik-mesine neden olmaktadır (2,3) .…”

Pediatric Rheumatology for the Primary Care Clinicians-Recognizing Patterns of Disease

“…[145][146][147] A child with neuroblastoma may complain of leg pain, particularly when the tumor is retroperitoneal. 148 Children with osteosarcoma or Ewing's sarcoma also have limb pain and limp.…”

Bony presentations of childhood haematological malignancy to the emergency room

“…[13][14][15] The incidence of malignancy in children with musculoskeletal complaints in a rheumatological unit is less than 1%. 16,17 Mean Fig. 3 Disposition of the undiagnosed emergency room (ER) visits.…”