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Joseph Junewick, MD FACR
over 10 years ago
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Case History

4 year old with several week history of arthralgias and pancytopenia.

Case Detail

Anatomy: Musculoskeletal
Joseph Junewick, MD FACR
Diagnostic Category: Neoplasia Malignant
Created: over 9 years ago
Updated: over 9 years ago
Tags: PEDS
Modality/Study Types: CR
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Reveal Clinical Notes

Bone marrow biopsy – Acute lymphoblastic leukemia with precursor B

Reveal Findings

CR – Permeative osteolysis of the proximal metaphysis of the fibula and associated periostitis. Also note the subphyseal metaphyseal lucent bands of the distal femur, proximal tibia and proximal fibula.

Reveal Discussion

Patients with bone pain and leukemia often have normal or nearly normal hematological studies and consequently osseous manifestations are still often a key to diagnosis. Approximately 20% of patients have musculoskeletal symptoms (limp, bone pain and arthralgias) at presentation although osseous lesions are most common less than 5 years of age.

Radiographic abnormalities include osteoporosis, transverse lucent metaphyseal bands, focal destruction, periostitis, permeative osteolysis and diffuse osteosclerosis. Metaphyseal lucent bands may be related to metabolic dysfunction or leukemic infiltration and are most commonly seen around the knee. Focal destruction (chloroma) is related to focal accumulations of leukemic cells. Chloromas can occur in any bone (usually the metaphysis) as a result of myeloid type leukemia. Periostitis is the result of leukemic extension from the marrow to the cortex through the Haversian canals and/or subperiosteal hemorrhage. Osteosclerosis is associated with myelogenous leukemia is likely related to activation of marrow derived osteoblasts.

Other less commonly osseous manifestations include permeative osteolysis, cortical erosions, pathologic fractures (vertebra plana), and avascular necrosis. Osseous manifestations of leukemia are not specific; similar abnormalities are seen with other malignancies (e.g., neuroblastoma), metabolic disease, and infection.

Reveal Diagnosis


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