Pallor and Limb pain
Sam is a 13 year-old boy with a few weeks history of tiredness and lethargy. When he gets home from school, he lies on the sofa and watches the TV; he used to go out and play on his bike with his friends, but now says he doesn’t feel like it. Sam has also noticed that his legs have been achy, particularly his right leg. In the last 3 weeks he has been waking up at night with his legs aching. He was previously very active, cycling and playing football, but is now struggling to take part in PE at school due to tiredness and feeling cold; he has also been reluctant to play with his friends after school. He has been struggling to recover from repeated viral infections over the last few months, but there have been lots of viral type illness going round at school. Mum noticed he seemed very thin when he was on stage during the school play.
On examination, Sam was thin and looked pale. It was noted he had some bruising around shins and calves. His chest was clear and heart sounds were normal. He had no joint abnormalities on pGALS examination. Abdominal examination showed hepatosplenomegaly.
His GP checked some urgent blood tests and arranged an early review appointment.
Lethargy, malaise, possible weight loss, night pain.
Leukaemia, primary bone tumour, post viral fatigue and streptococcal infection should all be considered.
You may consider arthritis, e.g. Juvenile Idiopathic Arthritis (JIA), or a reactive arthritis secondary to a recent infection, as well as considering malignancy.
The blood test results were as follows: haemoglobin 9 g/l, platelets 12 x106, white cell count 42 x 106 (neutrophils 20% and lymphocytes 80%). A bone marrow aspiration and biopsy showed blast cells suggestive of Acute Leukaemia.