Manifestaciones Musculoesqueléticas de Neoplasias en Pediatría a propósito de tres Casos Clínicos / Musculoskeletal manifestations of neoplasms in children: three reported cases

Introducción: El dolor musculoesquelético (ME) es un motivo de consulta común en la infancia originado en su mayoría por causas banales. Entre las causas menos frecuentes encontramos las patologías reumatológicas y neoplásicas. Se presentan tres casos clínicos que debutaron con artritis o artralgia en los cuales el diagnóstico final fue neoplásico. Casos clínicos: el primer caso fue una Leucemia Linfoblástica Aguda (LLA) de alto riesgo, el segundo caso fue un sarcoma de Ewing y el tercer caso fue una LLA común. Dos de los casos tuvieron evolución desfavorable con fallecimiento. Revisión de la literatura: Se describen hallazgos que deben hacer sospechar una causa neoplásica tales como el dolor ME desproporcionado, alteraciones en el hemograma, velocidad de eritrosedimentación globular y lactato deshidrogenasa elevados, y radiografía con alteraciones sugerentes. Conclusiones: Frente a un dolor ME en el niño se debe tener presente las causas neoplásicas a pesar de su baja frecuencia dado su mal pronóstico.

Introduction: Musculoskeletal (MS) pain is a common complaint in childhood, usually caused by trivial ailments. Among less frequent causes we may find rheumatological and neoplastic pathologies. We present 3 clinical cases in which a rheumatological cause was initially suspected, as they started out with arthritis or arthralgia, but where the diagnosis was finally a neoplasm. Clinical cases: the first case was a high-risk Acute Lymphoblastic Leukemia (ALL), the second case was a Ewing's sarcoma, and the third case was a common ALL. Two of the cases had unfavourable outcomes and passed away. Literature review: Findings that should make us suspect neoplastic causes are disproportionate MS pain, altered hemogram, elevated erythrocyte sedimentation rate and lactate dehydrogenase, and an x ray with suggestive alterations. Conclusions: When faced with MS pain in children, neoplastic causes must be taken into account despite their low frequency given the poor prognosis associated with the diagnosis.

A Case of Adult Acute Myeloid Leukemia Presenting with Musculoskeletal Manifestations / 대한류마티스학회지

Leukemia is a heterogenous group of neoplasms that arise from the malignant transformation of hematopoietic cells. The usual presentation is one of lethargy, pallor, fever, purpura, bleeding, etc, and all this is secondary to a decrease in the production of normal blood components. However, leukemia often manifests with musculoskeletal symptoms without a systemic presentation. Musculoskeletal symptoms that precede the recognition of leukemia are much less frequent in adults as compared to those in children, and this causes diagnostic confusion and a delayed diagnosis. We describe here a case of adult acute myeloid leukemia in which pain and weakness of the limbs were the main manifestations and these were suspected as being symptoms of musculoskeletal disease.

Comprometimento musculoesquelético como primeira manifestação de neoplasias / Musculoskeletal involvement as a first manifestation of neoplasm disease

OBJETIVO: Identificar pacientes portadores de neoplasias encaminhados ao ambulatório de reumatologia pediátrica por apresentarem sintomas musculoesqueléticos como manifestação inicial, bem como apontar os achados clínicos, laboratoriais e radiológicos que contribuíram para o esclarecimento diagnóstico. MÉTODOS: Foi realizada análise retrospectiva dos prontuários dos pacientes com diagnóstico final de neoplasia, que foram avaliados na Unidade de Reumatologia do Instituto da Criança - FMUSP entre janeiro de 1983 e dezembro de 2006. Foram registrados os dados referentes às queixas musculoesqueléticas, exame físico, provas laboratoriais e procedimentos radiológicos e invasivos realizados. RESULTADOS: Dos 4876 pacientes, 25 (0,5 por cento) crianças foram estudadas, sendo que 52 por cento apresentavam leucemia linfóide aguda - LLA e 24 por cento neuroblastoma. Vinte crianças (80 por cento) apresentaram artrite e/ou artralgia no início da doença. Todos os pacientes apresentavam sintomas constitucionais, sendo febre o mais prevalente (22 casos - 88 por cento). O hemograma inicial estava alterado em 16 pacientes (64 por cento), mas presença de blastos no sangue periférico foi observada em apenas dois pacientes. Onze pacientes demonstraram alterações evolutivas nos hemogramas seriados. Radiografias simples se mostraram alteradas em 11/14 pacientes, ultra-som em 12/18, cintilografia em 5/5, tomografia em 7/9 e ressonância em 3/3. O mielograma estava alterado em 18/22 pacientes, três deles apenas na repetição do exame. CONCLUSÃO: Queixas musculoesqueléticas são manifestações iniciais freqüentes das neoplasias, em especial da LLA, que devem ser consideradas no diagnóstico diferencial das doenças reumatológicas. Os hemogramas podem ser inicialmente normais, sendo necessário seu seguimento evolutivo. Exames de imagem e punção de medula óssea demonstraram ser fundamentais no diagnóstico.

OBJECTIVE: To describe the clinical and laboratory findings that contributed for the diagnosis of neoplasia in patients with musculoskeletal symptoms at presentation. METHODS: Retrospective analysis of medical records from patients with final diagnosis of neoplasia attended at the "Unidade de Reumatologia do Instituto da Criança - FMUSP" between January 1983 and December 2006. Data on musculoskeletal complaints, clinical examination, laboratory tests, radiological studies and diagnostic procedures were obtained. RESULTS: From 4876 patients, 25 (0.5 percent) children were studied (52 percent with acute lymphoid leukemia and 24 percent with neuroblastoma). Twenty children (80 percent) presented arthritis and/or arthralgia at onset of the disease. All patients presented systemic symptoms, such as fever (22 cases - 88 percent). The initial blood cell count was abnormal in 16 patients (64 percent), showing anemia and thrombocytopenia (12 and 5 cases, respectively). Blast cells were present in only two patients and eleven patients developed blood cell count abnormalities during follow-up. X-ray studies showed abnormalities in 11/14 patients, ultrasound in 12/18, scintigraphy in 5/5, CT in 7/9 and MRI in 3/3. Bone marrow smear was abnormal in 18/22 patients, but in three of them the abnormalities were not detected by the first test. CONCLUSION: Musculoskeletal symptoms are common at the onset of neoplasia, especially for acute lymphoid leukemia, and this possibility should be considered in the differential diagnosis of rheumatic diseases. Laboratory tests may be normal at the onset of the disease, therefore serial exams should be performed. For a correct diagnosis. radiological studies and bone marrow aspiration have proven to be essential.