P090 Rheumatic symptoms as the first manifestations of underlying systemic disorders
Authors: Unadkat Megha , Migowa Angela 
Published: November 2021

Abstract

Background
Joint and limb pain is a common presenting complaint within the paediatric population, affecting 10–20% of school-age children. They are also a major reason for referral to paediatric rheumatology clinics (1). The differential diagnosis for joint pain and/or swelling can include both benign and malignant causes. Studies have found that &lt; =1% of musculoskeletal complaints are caused by neoplasia, mostly acute lymphoblastic leukaemia (ALL) (1). It is essential to exclude life-threatening conditions such as infections and malignancies before initiation of treatment for presumptive Juvenile Idiopathic Arthritis (JIA) (2). The objective of this case series is to highlight the musculoskeletal features and the clinical course among children with haematological malignancies.

Methods
Charts of patients referred from rheumatology clinic to the haemato-oncology clinic were selected. A detailed chart review was then carried out to obtain information on clinical presentation, diagnostic work up and clinical progress of the patient.

Results
Case 1
CS, A 2 year and 2 months old girl who presented to paediatric rheumatology clinic with 5 month history of lower limb pain associated with a fever of 40’C. The pain progressively worsened leading to inability to walk. She had previously been treated for Idiopathic Thrombocytopenic Purpura with steroids. Initial Bone Marrow Aspiration (BMA) had ruled out leukaemia. Four months later, her condition had worsened and was referred to our facility where a peripheral blood film and flow cytometry confirmed B cell ALL. Treatment was initiated but unfortunately the patient’s condition deteriorated and eventually passed away.
Case 2
NM, a 2 year and 10 months old girl presented to our paediatric rheumatology clinic with bilateral foot pain for 8 weeks. She was initially limping and progressed to inability to walk within a month. Rheumatology review in Tanzania diagnosed the patient as JIA and started on steroids. On examination, systemic findings were normal except bilateral ankle joint effusion and tenderness. An X-ray displayed bilateral transverse lucencies in the metaphyseal ends of the tibia and fibula. BMA was done and confirmed ALL. Treatment was initiated and the patient attained remission after 18 months of therapy. She remains well 2 years after completion of therapy.
Case 3
NC, a 4-year-old girl, presented with multiple joint pains for 2 weeks. Pain was associated with night awakening and recurrent fevers. C-Reactive Protein (CRP) was persistently high and was treated with several courses of antibiotics. She was assessed by a haemato-oncologist with unremarkable findings. A decision was made to do a BMA and flow cytometry, which confirmed B cell ALL.

Conclusion
Musculoskeletal complaints are frequently the initial manifestations of acute leukaemia in childhood (60%) and should be considered in the differential diagnosis of JIA (3).
Initially laboratory test results can be normal therefore it is necessary to follow these children closely and request serial tests, until there is a clearly defined diagnosis of neoplasia.
Finally, malignancy should be eliminated before introduction of immunosuppressive therapy as the use of steroids may mask and delay its diagnosis (2).