1 case of acute mononucleoblast leukemia in children misdiagnosed as juvenile arthritis

1 case informationchild, 5 years and 10 months, the child's family member told the child 10d before no obvious cause steaming right knee joint pain, burst, mostly night pain, no obvious activity disorder, has been treated in Jiangxi Children's Hospital orthopaedic and rheumatology clinic, improve joint color super and put pa Fulin oral, symptoms slightly improved, but the child a week ago has a history of sprains, sprains after the left ankle swelling and left knee pain, and the family found that the child's palm joint swelling, for further diagnosis and treatment, then in the clinic proposed "juvenile arthritis" treatment in the rheumatoid immunology departmentAdmission, T:37C, P:86th/ min, R:20times/min, Bp: 108/78mmHg, weight: 18KgSkin mucous membranes: no rash, no subcutaneous bleeding, no edemaLymph nodes: the ear and neck can and multiple soybean-sized lymph nodes, no obvious tendernessPharynx: congestion, tonsill II swelling, no pus secretionsHeart rate: 86 times/min, heart rhythm, strong heart tone, unheard of and pathological heart murmursAbdominal: no pack, no pressure pain, no anti-jump pain, no swelling of the liver, no swelling of the spleen, normal intestinal soundSpinal limbs: no malformation, slight swelling of the left ankle, tenderness, no swelling of the residual joint, pressure pain in the left knee joint, no obvious pressure pain in the right knee joint and double hip joint, barrier-free activity, positive left 4 words, negative on the right 4 wordsNervous system: limb muscle strength, muscle tension is normal, abdominal wall reflection is normal, double knee reflection is normal, double-sided papal sign negative, two-sided keratin negative, two-sided brahmionOutpatient color overshow: right hip and knee fluidLaboratory examination: in addition to blood sink (ESR) 41mm/h, lactic acid dehydrogenase (LDH) 657U/L, C reactive protein (CRP) 28.05mg/L increase, other indicators of rheumatism factor (RF), antistcoccal hemolytic o (ASO), ANA (antinuclear antibody) and other results are normalBlood routine WBC: 9.78 x 10?9/L, RBC: 3.79 x 10?12/L, HGB: 108g/L, NE13.30%, LY40.4%, MO44.10%, PLT: 373 x 10?9/LThe blood routine results suggest that the total number of white blood cells is normal, mild anemia, the proportion of mononucleocytes increases, and the scatterplot suggests that the single-core cell is abnormally higher, as shown in Figure 1Blood cell morphology: Under the mirror shows that childish cells may be seen, see Figure 2, immediately telephone contact tube bed doctor, recommended bone marrow puncture examinationBone marrow smears, as shown in Figure 3: Bone marrow hyperplasia was significantly active, and the single-core system was abnormally hyperplasia, accounting for 83.5%The characteristics of the original young single nucleocyocyocy: cell is larger, irregular shape, the cell pulp is rich, opaque gray blue, can be seen a small number of small natural-color blue particles, cell nucleus large, round, easy to see distortion, folding, leaf and other phenomena; Lymphocytes accounted for 3%, and the three-line red-grain macro was significantly suppressedDiagnosed with acute myeloid leukemia (AML) M5After perfecting the examination of bone marrow puncture, then transferred to the hematology departmentImmune fraction 1 myelin is marked CD13:97%, CD33:98.07%, CD14:91.45%, T-gonoline cd2:49.75%, CD7:4.17%, B-syllot CD 19:2.01%, CD10:1.57%, CD22:3.26% Other CD34:9.46%, diagnosed as AML-M5, given the treatment after the disease improved, the current patient in follow-upto be discussed
2 In recent years, the incidence of childhood leukemia has increased year by year, reaching 3/100,000 to 4/100,000, of which acute leukemia accounts for about 30% of childhood tumorsAcute leukemia is also divided into acute lymphoblastic leukemia (ALL) and acute myeloid leukemia (AML), children are more common, accounting for about 70% to 85% of childhood leukemiaAML-M5 (acute monocytomyl leukemia) accounts for about 10% of acute myeloid leukemia, the symptoms of common leukemia it has, but its skin mucosa damage, rash, gum growth, swelling, bleeding, ulcers, necrosis and other immersion symptoms are more obviousLiver spleen and lymph node swelling is enlarged for its organs, and kidney damage is more common than other typesJuvenile arthritis (also known as juvenile isoarthritis) is one of the most common rheumatisms in childrenThe disease is numerous, such as juvenile rheumatoid arthritis, chronic arthritis in early childhood, Still's disease, etcThe most frequent groups of the disease are children aged 4 years and older, whose symptoms are fever, rash, joint pain, liver spleen and lymph node swellingThe results showed that the blood elephant was mild anemia, most patients had acute stage reactions, and the results of blood depression increasedTo date, there has been a lack of effective methods for the diagnosis of such diseases, mainly relying on exclusionAcute leukemia can also be associated with section pain, joint pain can also be its first symptoms, according to the data show that the first symptoms of joint pain in children with leukemia patients in the majority of patients, but it is worth noting that the majority of acute leukemia joint pain is not red, swollen, hot performanceIn patients with leukemia with bone joint pain, the possible mechanism of production is the leaching of tumor cells, and other possible mechanisms include a sliding membrane reaction to bone or envelope leaching, hematoma and immune complex-induced sliding diaphragm It has also been reported in the literature that acute leukemia bone and joint lesions in children are most common in children with acute lymphocytic leukemia (ALL) This case with ESR and CRP elevation indicates acute inflammatory response, blood routine only manifests as mild anemia, mononucleocyan increase, it is difficult for clinicians to associate with the diagnosis of acute leukemia, the first symptom is joint pain and diagnosed as a child AML-M5 (acute monocytotic leukemia) is extremely rare in clinical practice The most common pediatric malignant tumor in China is acute leukemia, the early symptoms of the case is very easy to misdiagnosis, its misdiagnosis rate as high as 36% to 58% The emergence of this case reminds the inspectors, peripheral blood morphology and the establishment of laboratory patch retest rules are very important, in the daily work encountered abnormal scatterplot map need to be timely re-test, in order to early to assist the clinical identification of the cause And for such special cases also remind clinicians, need to pay attention to peripheral blood cell morphology, bone marrow elephant, bone marrow cell flow and other examination, but also warned clinicians in the course of diagnosis and treatment must be "cautious, dedicated" attitude towards patients, and strive to improve professional standards, timely diagnosis, timely treatment references