Clinical Rheumatology

, Volume 28, Issue 11, pp 1253–1258 | Cite as

Predictive plain X-ray findings in distinguishing early stage acute lymphoblastic leukemia from juvenile idiopathic arthritis

  • Farhad Tafaghodi
  • Yahya Aghighi
  • Hadi Rokni Yazdi
  • Madjid Shakiba
  • Ali Adibi
Original Article

Abstract

Acute lymphoblastic leukemia (ALL) presenting with musculoskeletal pain may be difficult to distinguish from juvenile idiopathic arthritis (JIA). The objective of this study, which separates it from most studies investigating these two diseases, is to determine the role of plain radiography in the initial approach toward patients presenting with musculoskeletal symptoms and to look for signs suggestive of each of the two disease entities. X-rays of patients referred to our center for musculoskeletal symptoms and ultimately diagnosed with JIA or ALL over a period of 10 years were studied retrospectively. The X-rays had been performed in the preliminary stage of the disease process and before the initiation of specific therapeutic measures. Soft tissue swelling, osteopenia, radiolucent metaphyseal bands, coarse trabeculation, and periosteal reactions were studied, and data analysis was performed by SPSS. Among a total of 174 patients, 118 had been diagnosed with JIA and 56 with ALL. The average age of JIA patients and ALL patients were 7.5 and 7.2 years, respectively. Soft tissue swelling was significantly more common among JIA patients (89.8%) than among those with ALL (1.8%) (P < 0.0001). Therefore, it is of the utmost importance to note the presence or absence of soft tissue swelling on plain radiography in the initial diagnostic approach. Osteopenia was seen in 60.2% of JIA patients compared with 14.3% of ALL patients (P < 0.0001). Radiolucent metaphyseal bands were seen among 7.1% of ALL cases but were notably absent in all cases of JIA. Coarse trabeculation was significantly higher in patients with ALL (7.1% ) than among JIA patients (0.8%). Periosteal reactions were seen in 6.8% of JIA group compared with 1.8% of ALL patients. We concluded that plain X-ray may be useful in selecting patients requiring bone marrow examination among those presenting with musculoskeletal symptoms mimicking JIA.

Keywords

Acute lymphoblastic leukemia Juvenile idiopathic arthritis Osteopenia Plain X-ray Soft tissue swelling 

Notes

Acknowledgment

We are very thankful of Dr. Mehranoosh Dolatshahi for her assistance in editing the paper draft.

Disclosures

None

References

  1. 1.
    Jung A, Nielsen SM (1998) Arthritis as a first symptom of leukemia in children. Ugeskr Laeger 160(19):2889–2890PubMedGoogle Scholar
  2. 2.
    Jonsson OG, Sartain P, Ducore JM, Buchannan GR (1990) Bone pain as an initial symptom of childhood acute lymphoblastic leukemia: association with nearly normal hematologic indexes. J Pediatr 117(2pt 1):233–237PubMedGoogle Scholar
  3. 3.
    Revesz T, Kardos G et al (1985) The adverse effect of prolonged prednisolone pretreatment in children with acute lymphoblastic leukemia. Cancer 55:1637–1640PubMedCrossRefGoogle Scholar
  4. 4.
    Murray MJ, Tang T et al (2004) Childhood leukaemia masquerading as juvenile idiopathic arthritis. Br Med J 329:951–961Google Scholar
  5. 5.
    Barbosa CM, Nakamura C et al (2002) Musculoskeletal manifestations at the onset of acute leukemias in childhood. J Pediatr 78(6):481–484Google Scholar
  6. 6.
    Cabral DA, Tucker LB (1999) Malignancies in children who initially present with rheumatic complaints. J Pediatr 134:53–57PubMedCrossRefGoogle Scholar
  7. 7.
    Murray RO, Jacobson HG, Stoker DJ (1990) The radiology of skeletal disorders, 3rd edn. Churchill Livingstone, New York, p 538Google Scholar
  8. 8.
    Evans TI, Nercessian BM, Sanders KM (1994) Leukemic arthritis. Semin Arthritis Rheum 24:48–56PubMedCrossRefGoogle Scholar
  9. 9.
    Tsai MJ, Yan DC, Chiavg BL et al (1995) Childhood leukemia mimicking juvenile rheumatoid arthritis. Zhonghua Min Guo Xiao Er Ke Yi Xue Hui Za Zhi 36(4):274–278PubMedGoogle Scholar
  10. 10.
    Bradlow A, Barton C (1991) Arthritic presentation of childhood leukemia. Postgrad Med J 67:562–564PubMedCrossRefGoogle Scholar
  11. 11.
    Ostrov BE, Goldsmith DP, Athreva BH (1993) Differentiation of systemic juvenile rheumatoid arthritis from acute leukaemia near the onset of disease. J Pediatr 122:595–598PubMedCrossRefGoogle Scholar
  12. 12.
    Jones OY, Spencer CH, Bowyer SL, Dent PB, Gottlieb BS, Rabinovich CE (2006) A multicenter case–control study on predictive factors distinguishing childhood leukemia from juvenile rheumatoid arthritis. J Pediatr 117:840–844CrossRefGoogle Scholar
  13. 13.
    Swischuk LE (2004) Imaging of the newborn, infant, and young child, 5th edn. Lippincott Williams & Wilkins, Philadelphia, p 781Google Scholar
  14. 14.
    Resnick D (2002) Diagnosis of bone and joint disorders, 4th edn. Saunders, Philadelphia p 242Google Scholar
  15. 15.
    Rogalsky RJ, Black GB, Reed MH (1986) Orthopaedic manifestations of leukemia in children. J Bone Joint Surg Am 68:494–591PubMedGoogle Scholar
  16. 16.
    Haddy TB, Mosher RB, Reaman GH (2001) Osteoporosis in survivors of acute lymphoblastic leukemia. The Oncologist 6(3):278–285PubMedCrossRefGoogle Scholar
  17. 17.
    Edeiken J, Dalinka M, Karasick D (1990) Edeiken’s Roentgen diagnosis of diseases of bone, 4th edn. Williams & Wilkins, Baltimore, pp 468–472Google Scholar
  18. 18.
    Resnick K (2005) Bone and joint imaging, 3rd edn. Elsevier Saunders, Philadelphia, pp 685–687Google Scholar
  19. 19.
    Müller HL, Horwitz AE, Kühl J (1998) acute lymphoblastic leukemia with severe skeletal involvement: a subset of childhood leukemia with a good prognosis. Pediatr Hematol Oncol 15(2):121–133PubMedCrossRefGoogle Scholar
  20. 20.
    Sinigaglia R, Gigante C, Bisinella G et al (2008) Musculoskeletal manifestations in pediatric acute leukemia. J Pediatr Orthop 28:20–28PubMedGoogle Scholar
  21. 21.
    Benoit Y, Delbeke MJ, Eggesbø ES (1981) Skeletal changes in children with acute lymphoblastic leukemia. Tijdschr Kindergeneeskd 49:153–159PubMedGoogle Scholar
  22. 22.
    Trapani S, Grisolia F, Simonini G et al (2000) Incidence of occult cancer in children presenting with musculoskeletal symptoms. A 10-year survey in a pediatric rheumatology unit. Semin Arthritis Rheum 29:388–359CrossRefGoogle Scholar
  23. 23.
    Dahnert W, Müller HL, Hormitz AE (2003) Radiology review manual, 5th edn. Lippincott Willims & Wilkins, Philadelphia, p 110Google Scholar
  24. 24.
    Greenfield GB (1990) Radiology of bone diseases, 5th edn. Lippincott, Philadelphia, pp 509–512Google Scholar

Copyright information

© Clinical Rheumatology 2009

Authors and Affiliations

  • Farhad Tafaghodi
    • 1
  • Yahya Aghighi
    • 2
  • Hadi Rokni Yazdi
    • 3
  • Madjid Shakiba
    • 4
  • Ali Adibi
    • 1
  1. 1.Medical Imaging Center, Imam Khomeini Hospital ComplexTehran University of Medical SciencesTehranIran
  2. 2.Department of Pediatrics, Division of Pediatric Rheumatology, Vali-E-Asr HospitalTehran, University of Medical SciencesTehranIran
  3. 3.Department of Radiology, Imam Khomeini Hospital ComplexTehran University of Medical SciencesTehranIran
  4. 4.Medical Imaging CenterTehran University of Medical SciencesTehranIran

Personalised recommendations