Abstract
Acute lymphoblastic leukemia (ALL) often presents with osteoarthritic manifestations which may lead to misdiagnosis with juvenile rheumatoid arthritis (JRA). This study was designed to identify ALL patients with initial diagnosis of JRA, compare their clinicolaboratory characteristics and outcome with other ALL patients treated at our center. Case records of 762 patients with ALL were analyzed. Information regarding the clinical-demographic profile, therapy and outcome were recorded. Of the children, 49 (6.4%) had initial presentation mimicking JRA. Asymmetric oligoarthritis was the most common pattern of joint involvement. Majority presented with fever, pallor, arthritis, night pain, and bone pain. None of the routine prognostic factors including age, gender, lymphadenopathy, hepatosplenomegaly, total leukocytes count (TLC), and platelet count were significantly associated with relapse/death. The mean symptom-presentation interval (SPI), hemoglobin was significantly higher whilst the TLC was significantly lower in these patients compared to other ALL patients. The 5 year overall-survival was better than other patients with ALL (p = 0.06, by logrank test). Significantly longer SPI in these patients underscores the need for prompt and early investigations to rule out ALL in patients of JRA with atypical features and pointers of ALL. Children with ALL-mimicking JRA may belong to a subgroup of ALL with a better prognosis.
Similar content being viewed by others
References
Manners PJ, Bower C (2002) Worldwide prevalence of juvenile arthritis—why does it vary so much? J Rheumatol 29:1520–1530
Margolin JF, Poplack DG (1997) Acute lymphoblastic leukemia. In: Pizzo PA, Poplack DG (eds) Principles and practice of pediatric oncology. Lippincott-Raven Publishers, Philadelphia, PA, pp 409–482
Cabral DA, Tucker JB (1999) Malignancies in children who initially present with rheumatic complaints. J Pediatr 134:53–57
Schaller J (1972) Arthritis as a presenting manifestation of malignancy in children. J Pediatr 81:93–797
Bowyer SL, Hollister JR (1984) Limb pain in childhood. Pediatric Clin North Am. 31:1053–1349
Fink CW, Windmiller J, Sartain P (1972) Arthritis as the presenting feature of childhood leukemia. Arthritis Rheum 15:347–349
Ostrov BE, Goldsmith DP, Athreya BH (1993) Differentiation of systemic juvenile rheumatoid arthritis from acute leukemia near the onset of disease. J Pediatr 122:595–598
Sills EM (1973) Errors in diagnosis of juvenile rheumatoid arthritis. Johns Hopkins Med J 133:88–95
Jonsson OG, Sartain P, Ducore JM, Buchanan GR (1990) Bone pain as an initial symptom of childhood acute lymphoblastic leukemia: association with nearly normal hematologic indexes. J Pediatr 117:233–237
Silverstein MN, Kelly PJ (1963) Leukemia with osteoarticular symptoms and signs. Ann Intern Med 59:637–645
Bichel J (1948) Arthralgic leukemia in children. Acta Haematol 1:154–164
Thomas LB, Forkner CE, Frei E, Besse BE, Stabenau JR (1961) The skeletal lesions of acute leukemia. Cancer 14:608–621
Rogalsky RJ, Black B, Reed MH (1986) Orthopaedic manifestations of leukemia in children. J Bone Joint Surg [Am] 68:494–501
Bradlow A, Barton C (1991) Arthritic presentation of childhood leukemia. Postgrad Med J 67:562–564
Chessells JM, Bailey CC, MRC RS, UKALL X (1992) The UK protocol for childhood ALL: 1985–1990. Leukemia 6:157–161
Chessells JM, Bailey C, Richards SM (1995) Intensification of treatment and survival in all children with lymphoblastic leukemia: results of UK Medical Research Council trial UKALL X. Medical Research Council Working Party on Childhood Leukaemia. Lancet 11(8950):345–653
Cassidy JT, Petty RE (2001) Juvenile rheumatoid arthritis. In: Cassidy JT, Petty RE (eds) Textbook of pediatric rheumatology. WB Saunders, Philadelphia, PA, pp 218–321
Barbosa CM, Nakamura C, Terreri MT, Lee ML, Petrilli AS, Hilário MO (2002) Musculoskeletal manifestations at the onset of acute leukaemias in childhood. J Pediatr (Rio J) 78:481–484
Kai T, Ishii E, Matsuzaki A, Okamura J, Ikuno Y, Tasaka E, Ueda K (1996) Clinical and prognostic implications of bone lesions in childhood leukemia at diagnosis. Leukaemia and lymphoma 23:119–123
Tsai MJ, Yan DC, Chiang BL, Chou CC, Hsieh KH, Lin KH (1995) Childhood leukaemia mimicking juvenile rheumatoid arthritis. Acta Paed Sin 36:274–278
Rashid AKMM, Al Mamun A, Ahasan HAMN, Rasul CH (2005) Leukaemia mimicking juvenile rheumatoid arthritis. Pak J Med Sci 21:85–87
Murray MJ, Tang T, Ryder C, Mabin D, Nicholson JC (2004) Childhood leukaemia masquerading as juvenile idiopathic arthritis. BMJ 329:959–961
Costello PB, Brecher ML, Starr JI, Freeman AI, Green FA (1983) A prospective analysis of the frequency, course, and possible prognostic significance of the joint manifestations of childhood leukemia. J Rheumatol 10(5):753–757
Schaller J (1972) Arthritis as a presenting manifestation of malignancy in children. J Pediatr 81(4):793–797
Trapani S, Grisolia F, Simonini G, Calabri GB, Falcini F (2000) Incidence of occult cancer in children presenting with musculoskeletal symptoms: a 10-year survey in a pediatric rheumatology unit. Semin Arthritis Rheum 29(6):348–359
Needleman M (1996) Childhood leukaemia mimicking arthritis. J Am Board Fam Pract 9:56
Robazzi TC, Barreto JH, Silva LR, Santiago MB, Mendonça N (2007) Osteoarticular manifestations as initial presentation of acute leukemias in children and adolescents in Bahia, Brazil. J Pediatr Hematol Oncol 29:622–626
Saulsbury FT, Sabio H (1985) Acute leukemia presenting as arthritis in children. Clin Pediatr (Phila) 24:625–628
Bowyer SL, Hollister JR (1984) Limb pain in childhood. Pediatr Clin North Am 31:1053–1081
Gonclaves M, Terreri M, Barbosa M, Len CA, Lee L, Hilário MO (2005) Diagnosis of malignancies in children with musculoskeletal complaints. Sao Paulo Med J [online] 123:21–23
Jones OY, Spencer CH, Bowyer SL, Dent PB, Gottlieb BS, Rabinovich EC (2006) A multicenter case-control study on predictive factors distinguishing childhood leukemia from juvenile rheumatoid arthritis. Pediatrics 117:e840–e844
Silverman LB, Gelber RD, Dalton VK et al (2001) Improved outcome for children with acute lymphoblastic leukemia: results of Dana–Farber Consortium Protocol 91–0. Blood 97:1211–1218
Chessells JM, Bailey C, Richards SM (1995) Intensification of treatment and survival in children with lymphoblastic leukaemia: results of UK Medical Research Council trial UKALL X. Medical Research Council Working Party on Childhood Leukaemia. Lancet 345:143–148
Shrappe M (2003) Prognostic factors in childhood acute lymphoblastic leukaemia. Indian J Pediatr 70:817–824
Conflict of interest
None.
Funding
None.
Author information
Authors and Affiliations
Corresponding author
Rights and permissions
About this article
Cite this article
Marwaha, R.K., Kulkarni, K.P., Bansal, D. et al. Acute lymphoblastic leukemia masquerading as juvenile rheumatoid arthritis: diagnostic pitfall and association with survival. Ann Hematol 89, 249–254 (2010). https://doi.org/10.1007/s00277-009-0826-3
Received:
Accepted:
Published:
Issue Date:
DOI: https://doi.org/10.1007/s00277-009-0826-3