The Implications of Musculoskeletal Manifestations in Acute Lymphoblastic Leukemia: A Decade's Experience from a
Konsam Samuel Lyngdoh1, Pandya Dhruti2, Sidharth Totadri3
1Department of Pediatrics, St. John's Medical College and Hospital, Bengaluru, Karnataka, 560034, India.
Insights
Children with acute lymphoblastic leukemia (ALL) and musculoskeletal symptoms often present with delayed diagnosis and preserved blood counts. Misdiagnosis as juvenile idiopathic arthritis (JIA) can lead to inappropriate treatment, impacting risk stratification and chemotherapy toxicity.
Area of Science:
- Pediatric Oncology
- Rheumatology
- Hematology
Background:
- Musculoskeletal (MSK) manifestations in pediatric acute lymphoblastic leukemia (ALL) can mimic juvenile idiopathic arthritis (JIA).
- This overlap can lead to misdiagnosis and delayed ALL treatment.
- Understanding differences in presentation and outcomes is crucial for timely diagnosis.
Purpose of the Study:
- To compare baseline characteristics and survival outcomes of ALL patients with and without MSK symptoms.
- To evaluate the impact of misdiagnosis as JIA on ALL management and outcomes.
Main Methods:
- Retrospective chart review of pediatric ALL patients (<18 years).
- Stratification into standard-risk (SR), intermediate-risk (IR), and high-risk (HR) groups.
- Comparison of clinical, laboratory features, and survival between ALL with and without MSK symptoms.
Main Results:
- 26% of ALL patients had MSK manifestations; 9 were pretreated for JIA.
- MSK group had longer symptom duration (4 vs 2 weeks) and higher median platelet counts.
- 3-year event-free survival was similar (84.4% vs 78.9%), but pretreatment confounded risk stratification.
Conclusions:
- Pediatric ALL with MSK symptoms presents with delayed diagnosis and better baseline blood counts.
- Misdiagnosis as JIA and subsequent pretreatment can delay ALL diagnosis and complicate risk stratification.
- Appropriate risk stratification is essential to avoid unnecessary toxic chemotherapy.
Objective:
Children with acute lymphoblastic leukemia (ALL) with musculoskeletal (MSK) manifestations may be misdiagnosed as juvenile idiopathic arthritis (JIA). The present study compared the baseline parameters and survival outcomes in patients with ALL with and without MSK symptoms.
Methods:
A retrospective chart review of children aged < 18 years diagnosed with ALL was performed. Based on contemporary parameters, the patients were stratified into standard-risk (SR), intermediate-risk (IR), and high-risk (HR) groups. Clinical and laboratory features and survival outcomes were compared between ALL patients with and without MSK symptoms.
Results:
Out of 255 participants, 67 (26%) had MSK manifestations; of these, 9 were pretreated for JIA with glucocorticoids/methotrexate. Patients with MSK manifestations had a longer median duration of symptoms before diagnosis (4 vs 2 weeks, P < 0.001), and a higher median platelet count (53 × 109/L vs. 28 × 109/L, P = 0.002). The 3-year event-free survival (EFS) for patients with MSK and without MSK manifestations were 84.4 ± 5.2% and 78.9 ± 3.4% (P = 0.900). All 9 pretreated patients received an IR/HR protocol (4 were SR if not for the pretreatment as JIA).
Conclusion:
Patients with ALL with MSK manifestations have more preserved blood counts and a longer duration of symptoms before diagnosis. Pretreatment of children with ALL misdiagnosed as JIA with glucocorticoids/methotrexate can delay the diagnosis, confound the risk stratification, and upstage the risk group requiring administration of more toxic chemotherapy than necessary otherwise.
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