S GuptaRheumatology Study day RMCH

10/5/2011

Presentation14 yrs old female1st time- 13/3/2011 to A & EPain in left thigh for 1/7Xray of left thigh takenDischarged homeRepresented to the GP- 12/4/114/7 pain in lower back and both legs3/7 h/o fever Started period 4/7 ago

Negative H/oMouth ulcers, hair lossproximal muscle weaknessCough, weight loss, low grade feverNight sweatsForeign travelBut wasSpiking temps all day last 36 hours

Fever pattern

Bloods done by GPHb-12.3, WCC- 4.1, Neut- 2.1, plts- 77, CRP- 198No h/o foreign travelPregnancy test –negativeBlood film- leucoerythroblastic

Under Paeds team at RMCH

Seen by Haematologist

Given 5/7 of iv Benpen and Fluclox

MRI spine done

MRI ReportMultiple  small  areas  of  signal 

abnormality  inseveral  vertebral  bodies  and  possibly  in  the 

pelvis.  These  may  represent  multifocal  osteomyelitis,including  the  possibility  of 

TB,  or  other  infiltrative process.  Clinical 

correlation  is  suggested.

DifferentialInfection- Possibly TB osteomyelitis abscessInflammationInfiltration

Further testsMantoux- negativeQuantiferon- negativeESR- 118LDH- 1065Low WCC and low plateletsSpinal review sought- unlikely discitis

Opinion sought from Rheumatologist DD-1) Malignancy- ALL, Lymphoma, bony

metastasis, Neuroblastoma2) Infection- TB, Salmonella3) Lupus4) Chronic multifocal osteomyelitis

adviceBone marrow biopsyUrine catecholeaminesFerritinExclude TBUrgent- ANA, dsDNA, C3, C4, ANCA, IgGsCoombe’s testBone scan if biospy normal.

Bone marrow Infiltrated with population of large blastsLikely acute leukaemiaTranferred to Oncology wardCommencement of chemotherapyRapid improvement in her symptoms.