Osteolytic bone lesions, severe hypercalcemia without circulating blasts: unusual presentation of childhood acute lymphoblastic leukemia

Abstract

Hypercalcemia and severe osteolytic lesions are rare complications of acute lymphoblastic leukemia (ALL) in childhood. We report a case of a 3 years old boy who presented with prolonged fever, nausea, vomiting and increasing lower limbs pain. Skeletal X-rays and CT scan showed severe osteolytic lesions of the skull and extremities. Her physical examination showed multiple cervical lymph nodes. In laboratory tests, he had severe hypercalcemia. Parathyroid hormone (PTH) was not elevated. Despite the absence of circulating blasts, bone marrow biopsy revealed B-precursor (ALL). Hypercalcemia was initially treated with intravenous isotonic sodium chloride solution and diuretics but the serum calcium level normalized only after the beginning of corticosteroids and chemotherapy. The child responded initially to chemotherapy and eventually relapsed and died of septic shock. Acute leukemia must be considered in differential diagnosis in patients with hypercalcemia. A detailed examination even when there no circulating blasts in their peripheral blood smear, and if in doubt bone marrow aspiration should must be taken into consideration.

Hypercalcemia As the Sole Initial Presentation of Precursor B-cell Acute Lymphoblastic Leukemia

“…Studies suggest cytokines including interleukin (IL)-2, IL-6, tumor necrosis, PGE2, and TGF-alpha might mediate hypercalcemia in ALL [ 3 ]. The pathogenesis of malignancy-associated hypercalcemia is not completely understood but is thought to be the result of local osteolytic metastases or enhanced bone resorption mediated by proteins and cytokines released by tumor cells [ 4 ]. Calcitriol has been associated with granulomatous disorders and certainly lymphomas and is implicated in hypercalcemia.…”

Dolor óseo generalizado e hipercalcemia en un lactante mayor como síntoma inicial de linfoma linfoblástico de células B

“…Se han identificado cuatro tipos de hipercalcemia relacionados con malignidad: hipercalcemia asociada a neoplasias malignas, hipercalcemia osteolítica local, hipercalcemia inducida por 1,25-vitamina D y secreción ectópica de hormona paratiroidea auténtica [7][8][9] .…”

Hypercalcemia and Lytic Bone Lesions As a Rare Presentation of Acute Lymphoblastic Leukemia: A Case Report

“…Two general mechanisms explain malignancy-associated hypercalcemia, osteolytic lesions due to the direct invasion of the skeleton by tumor cells and the ectopic production of circulating factors that activate osteoclastic bone resorption. The main factors are the osteolytic PTH-related protein (PTHrp) [6].…”