5-year-old boy who is previously healthy presents with bilateral heel pain. he walks on his toes and limps to avoid heel pain. No other joints are involved. Anti-inflammatory medications provide some relief. No other symptoms. Physical examination is normal except: Tenderness is most pronounced over both calcanei, with the right being tenderer than the left. He has a mild antalgic gait with weight bearing. He prefers to walk on the balls of his feet to avoid putting pressure on his heels. All labs are normal including CBC and CRP except: Erythrocyte sedimentation rate is 28 mm/h. DD: The common causes of heel pain in children include calcaneal apophysitis (Sever disease), calcaneal stress fracture, osteomyelitis, and growing pains. Calcaneal apophysitis commonly affects active, prepubertal children and is characterized by pain in the posterior aspect of the heel after play. Radiographs of the calcaneus may appear normal or may reveal a fragmented and sclerotic calcaneal apophysis MRI: Figure 1 Magnetic resonance image of the foot with T1 postcontrast sequence shows enhancement throughout the bones consistent with marrow replacement disease MRI: Figure 2: Magnetic resonance image of the foot shows decreased T1 signal of the bones due to marrow replacement disease. A bone marrow biopsy aspiration of the right iliac crest revealed cells concerning for leukemia. Flow cytometry of these cells was consistent with precursor B-cell acute lymphoblastic leukemia (ALL). The most common laboratory abnormalities in ALL include anemia, thrombocytopenia, leukopenia, or leukocytosis, with hyperleukocytosis present in approximately 15% of pediatric patients. Children who have bone pain as the most prominent presenting symptom of ALL often have relatively normal blood cell counts Critical to know: Leukemia should be included in the differential diagnosis for any child with bone pain or a limp, especially without a history of trauma. Bone pain can be the only presenting symptom in leukemia. A delay in diagnosis of leukemia is common because initial laboratory test results and radiographs may be normal early in the disease Osama Naga
Posted on: Mon, 26 Jan 2015 00:12:52 +0000
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