2nd Department of Paediatrics, Semmelweis University Budapest, 1094, Tuzolto u 7-9, Budapest, Hungary.
Pediatr Rheumatol Online J. 2013 May 4;11:20. doi: 10.1186/1546-0096-11-20. eCollection 2013.
The initial symptoms of childhood leukaemia and lymphoma are often similar to those of juvenile idiopathic arthritis (JIA). In our study, we analyzed the frequency and characteristics of musculoskeletal complaints as the initial presenting symptoms of newly diagnosed leukaemia and lymphoma patients in the past 10 years in our clinic.
Using the Hungarian Tumour Register, we performed a retrospective analysis of the medical records of 166 new leukaemia and 95 new lymphoma pediatric patients treated from 1999 to 2009 at the 2nd. Dept. of Paediatrics of the Semmelweis University in Budapest.
Twenty percent of the leukaemic (33 children) and 2% of the lymphoma patients (2 children) had musculoskeletal symptoms at first presentation. Two-thirds of both groups of patients had other general symptoms like fever and/or fatigue. The hip was the most frequently affected joint (7/33) in the leukaemic patients. Twenty-four percent of all the children had been previously evaluated by an orthopaedist; 12% had visited another rheumatologist prior to diagnosis. Imaging had been done in an unexpectedly low number of patients prior to referral to our unit (radiographs: 16 or 48%, ultrasound: 5 patients or 15%). Radiographs of the affected joints were abnormal in only one case (1/16, 6%). The joint ultrasound was abnormal in only three children of 5 studied (3/5, 60%). Anaemia (26/32, 6%), thrombocytopenia (78%) and LDH elevation (3-4 times the normal count) were frequent in the leukaemic patients. Half of the cases had a normal leukocyte count. The lymphoma group had similar results. Two patients of the leukaemia group received steroid treatment before the final diagnosis. Severe pain out of proportion to physical findings is another clue.
Haematologic malignancies must be excluded before initiation of therapy for childhood arthritis among children presenting with musculoskeletal signs and symptoms, particularly in atypical cases. Malignancies are to be suspected when pain is disproportionately severe compared to the physical examination findings, and when anaemia, thrombocytopenia, and an elevated LDH level are present. Diagnosing leukaemia early is important because the use of steroids and immunosuppressive medications may mask and delay its diagnosis. Additionally, pre-treatment of presumed JIA patients with these drugs who eventually are diagnosed to have a malignancy may lead to the malignancy being steroid-resistant and more difficult to treat.
儿童白血病和淋巴瘤的初始症状常与幼年特发性关节炎(JIA)相似。在本研究中,我们分析了过去 10 年来我院新诊断白血病和淋巴瘤患儿以肌肉骨骼系统症状为首发表现的频率和特征。
利用匈牙利肿瘤登记处,我们对 1999 年至 2009 年在布达佩斯塞梅尔维斯大学第二儿科学系治疗的 166 例新发白血病和 95 例新发淋巴瘤患儿的病历进行了回顾性分析。
20%的白血病(33 例患儿)和 2%的淋巴瘤(2 例患儿)患儿以首发肌肉骨骼症状就诊。两组患儿中约三分之二均有其他全身症状,如发热和/或疲劳。白血病患儿中最常受累的关节为髋关节(33 例患儿中 7 例)。24%的患儿曾接受过矫形外科医生的评估;12%的患儿在诊断前曾就诊于其他风湿病医生。在转诊至我院之前,异常影像学检查的比例较低(X 线:16%或 48%,超声:5 例患儿或 15%)。在接受评估的患儿中,仅 1 例(16%,1/16)受累关节 X 线异常。5 例接受关节超声检查的患儿中,仅 3 例(60%,3/5)异常。贫血(26/32,60%)、血小板减少症(78%)和乳酸脱氢酶(LDH)升高(正常计数的 3-4 倍)在白血病患儿中较为常见。半数患儿白细胞计数正常。淋巴瘤组结果相似。白血病组中有 2 例患儿在最终诊断前接受了类固醇治疗。与体格检查结果不成比例的严重疼痛也是另一个提示。
在以肌肉骨骼症状和体征就诊的儿童中,尤其是在不典型病例中,开始关节炎治疗之前必须排除血液系统恶性肿瘤。当疼痛与体格检查结果不成比例严重,且存在贫血、血小板减少症和 LDH 水平升高时,应怀疑恶性肿瘤。早期诊断白血病很重要,因为使用类固醇和免疫抑制药物可能会掩盖和延迟其诊断。此外,最终诊断为恶性肿瘤的疑似 JIA 患儿在接受这些药物治疗前可能会导致肿瘤对类固醇耐药,更难以治疗。