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"Child`s Health" 6 (57) 2014

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Osteomyelitic mask of debut of lymphoblastic leukemia in child

Authors: K.V.Vilchevska, S. A. Kolomenska, K. M. Marchenko - Donetsk national medical University. M. Gorky

Categories: Pediatrics/Neonatology

Sections: Specialist manual

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Leukemia takes 38-40 % of all malignant neoplasms of the hematopoietic and lymphoid tissues. It occurs in both sexes with equal frequency (4 cases per 100,000 child population). The peak of incidence occurs between the ages of 2-5 years.

Acute lymphoblastic leukemia (ALL) - (ICD-X-S91.0) develops from malignant transformation of T-and B-lymphocytes’ precursors. Clinical manifestations and prognosis depend on the nature of ALL leukemic clone, the duration of the disease before the time of diagnosis, the degree of infiltration of the bone marrow by blasts and presence of extramedullary proliferation process. In this article we give our own clinical observation.

Anastasia N., aged 11, was admitted to the Department of Children Hematology at the Institute of Urgent and Recovery Surgery named after V.K. Husak NAMS of Ukraine in December 2013. She complained of fever up to 37,0-37,8 C, general weakness, weight loss, pain in the left angle of the mandible, lower lip numbness, occasional pain in the bones of the lower limbs and spine, serous- purulent discharge from the left ear.

She had been being ill from 2013, when she began to suffer from moderate pain in the left corner of the lower jaw, which was explained by the growth of the tooth VIII. In late July, during a holiday near the sea, she marked weakness and fatigue. In early August, there was a painful swelling in the angle of the mandible and numbness of the left part of lower lip. The study of peripheral blood revealed the increase of ESR 43 mm/hr, whereas  Hb - 124 g/l, erythrocytes - 3,7 T/L, leukocytes - 6,1 g/l, band forms - 5%, segmented forms - 65 %, lymphocytes - 26 %, monocytes - 4% . Odontogenic osteomyelitis was diagnosed and the girl was treated in the Department of Maxillofacial Surgery (she got blitsef, L-lysine, deksalgin). She was discharged with improvement. Two weeks later swelling and pain in the left mandibular angle reappeared, submandibular lymph nodes were painful, up to 1.0-1.5 cm in diameter, increased weakness, appetite deteriorated. In order to exclude myeloproliferative disease girl was consulted by a pediatric hematologist. These symptoms were estimated as recurrent osteomyelitis, and therefore the course of antibiotic therapy (augmentin, klatsid) and dimexidum - dressings and antibiotics locally - was continued. As a result of the treatment condition of the child improved, and lymph node swelling in the submandibular region decreased, but ESR in the peripheral blood remained increased to 17 mm /hr. 

After 3 months, in December, the child deteriorated again, there was a low-grade fever, periodically suffer from pain in the legs and back. During the five months she lost 5 kg. After consultation of Pediatric Hematology she was admitted to the Department of Children Hematology for further examination and treatment.

Patient is from II-pregnancy, II birth at 42 weeks. She was born with a double cord entanglement in the average degree of asphyxia. The child was put to breast at the 4-th day. Cancer family history is burdened by maternal line: great- grandmother and grandmother had breast cancer, great grandfather - cancer of the prostate gland.

At admission to the general condition of the child was moderate. Skin and visible mucous were clean, of normal color. There were moderately expressed facial asymmetry due to swelling in the cheek and the left angle of the mandible, painful on palpation. Peripheral lymph nodes in the submandibular region were up to 0.8-1.0 cm, other areas were not increased. Palatal and gums mucosa was not changed. In the lungs there was vesicular breathing. Abdomen was soft, painless on palpation; liver and spleen were not enlarged.

The patient was examined at the department. In the analysis of peripheral blood: Hb 119 g/l, erythrocytes - 3,9 T/L, leukocytes - 4,5 g/l, band forms- 5%, segmented forms - 8%, lymphocytes - 59 %, monocytes - 5 %, platelets - 57:1000, ESR 11 mm/hr.

In the myelogram: blasts - 93 %; lymphocytes - 3%; normoblasts - 4,0%, megakaryocytes were found.

Cytochemical analysis of the bone marrow was provided. Conclusion: lymphoblastic linearity blast cells, L1 due to FAB classification.

Analysis of cerebrospinal fluid revealed: cell count - 1 lymphocyte per 1 mm; protein 1 - 0,33 g/l; protein 2 - 0,32 g/l; Pandey reaction ±.

Total bilirubin level was within normal limits. DNA Cytomegalovirus, DNA Herpes Symplex virus ?, RNA HCV, HBV DNA were detected.

Chest radiography revealed no pathological changes.

Based on history, clinical picture and data of additional studies acute lymphoblastic leukemia, L1, common- B - version with the expression of CD33, an acute period was diagnosed.

The girl received treatment program ALL IC - 2009, 1st phase of the I protocol had finished. On the 33th day of treatment in the myelogram there were 8 % of blasts (remission - < 5 %), that was incomplete remission, and therefore the girl was transferred  into more intensive care units at high risk.

Thus, the debut of acute leukemia can take "mask" of odontogenic osteomyelitis (pain in the lower jaw, enlargement of regional lymph nodes and their pain, positive response to antibiotic therapy in the form of reduced morbidity and infiltration of the mandible with a decrease in lymph nodes and ESR). It causes difficulties for diagnosis of the disease and leads to delayed prescription of treatment.


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