Case Presentation: A healthy 6-year-old boy with an unremarkable family history sustained a minor trampoline injury accompanied by mild back and neck pain. The neck pain resolved within several days, but back pain persisted for two weeks. During that time, the patient also developed proximal muscle weakness and difficulty walking, prompting outpatient evaluation that revealed elevated inflammatory markers but was otherwise unremarkable. He was referred to neurology where he was noted to have globally decreased muscle tone and bulk and a positive Gower’s sign leading to admission for a workup of muscular dystrophy or myositis. Labs were remarkable for mild anemia (hematocrit 30.1 %) and elevated inflammatory markers (ESR 91 mm/hr). CPK was within normal limits. Muscle biopsy and spinal MRI were normal and he was discharged with physical therapy and neurology follow-ups. The patient re-presented two weeks later with worsening pain, fevers and weight loss. Exam at that time was notable for diffuse lymphadenopathy and hepatosplenomegaly. CBC was remarkable only for persistent mild anemia. Bone marrow biopsy revealed a predominance of small lymphoid blast cells leading to a diagnosis of standard risk acute lymphoblastic leukemia. Prior to diagnosis he was evaluated by his primary care physician, neurology, inpatient medicine, neurology, neurosurgery, general surgery, physical medicine and rehabilitation, PT/OT, hematology-oncology and rheumatology.
Discussion: Back pain presents a significant diagnostic dilemma for hospitalists. Although up to half of children have experienced back pain; they do not commonly seek medical attention for it and it is a concerning chief complaint in pediatric patients. While benign, non-specific musculoskeletal pain accounts for at least 50 percent of cases, more insidious causes must be considered including infection, inflammatory disease or neoplasm (including leukemia and primary or metastatic solid tumors) as well as referred pain from pancreatitis or cholecystitis. Warning features that warrant further workup include young age (<4 yrs), persistence of symptoms beyond 4 weeks, interference with function, constitutional symptoms, worsening pain, neurological symptoms, recent onset of scoliosis, history of trauma and failure of conservative treatment. A thorough history and physical are a necessity and further investigation may include laboratory workup and imaging. As with our patient, confounding symptoms may complicate the clinical picture and careful follow up as well as assiduous search for a conclusive diagnosis is necessary to avoid diagnostic delays.
Conclusions: As many as 25% of patients with leukemia present with severe bone pain. A high index of suspicion for this and other oncologic, infectious or inflammatory causes should be maintained during the workup of back pain, especially when alarm symptoms are present or conservative treatment has failed.
To cite this abstract:Emara N, Fey J. Occam’s Back Pain: A 6 Year Old with Leukemia. Abstract published at Hospital Medicine 2015, March 29-April 1, National Harbor, Md. Abstract 420. Journal of Hospital Medicine. 2015; 10 (suppl 2). https://www.shmabstracts.com/abstract/occams-back-pain-a-6-year-old-with-leukemia/. Accessed April 3, 2020.