Back Pain In a Five-Year Old Boy: A Harbinger of Tempest

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Salwa Hasan



Introduction: We describe a boy with back pain accompanied by normal physical, hematological and radiological findings prior to diagnosis of acute lymphocytic leukemia (ALL).

Case: A previously healthy, 5-year-old boy presented on 2 occasions to the emergency department with isolated nocturnal lower back pain. His back and neurologic exams were normal. The child’s investigations only showed low haemoglobin (99 g/L). Spine and chest x-rays were normal. The child’s third presentation with back pain occurred two months later, accompanied by fatigue and episodic fever.  His investigations showed an anemia (haemoglobin 37 g/L), thrombocytopenia (platelet count 200 X 109/L) and leukocytosis (leukocyte count 16.6 0 X 109/L) with neutropenia (neutrophil count 0.50 0 X 109/L). His blood smear showed 43% of circulating blasts. His bone marrow biopsy confirmed the diagnosis of early precursor B-ALL.

Discussion: Clinical findings of ALL at diagnosis tend to be non-specific and include fever and infection caused by neutropenia, bruising and bleeding from thrombocytopenia, and fatigue and pallor from anemia. Isolated bone pain as the initial presentation of ALL is uncommon. Children with ALL who present with prominent bone pain have hematological values that are closer to normal, as compared to those with no or mild bone pain. More than half of children with ALL who present with musculoskeletal symptoms have no radiological findings.

Conclusions: Given that clinical disease presentation of ALL is non-specific and often precedes hematological changes, a high index of suspicion for bone pain in young children may contribute to the early diagnosis of ALL.