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Abstract
In this report, we present a rare case of childhood ALL with hypercalcemia and extensive osteolytic lesions. The case was a 7-year-old girl presenting with vomiting and aggravating bone pain. Radiologic examinations showed severe osteolytic lesions of the skull and extremities. Laboratory findings revealed low hemoglobin, normal WBC count with absent circulating blasts, and an increased serum calcium level. Serum intact PTH and 1,25-(OH)2 vitamin D3 levels were below the normal ranges and parathyroid hormone-related peptide (PTHrP) was not detected, whereas serum levels of prostaglandin E2 were elevated. The hypercalcemia resolved with specific antileukemic chemotherapy along with supportive care. The elevated plasma prostaglandin E2 levels decreased slightly after complete remission with induction chemotherapy. These findings suggest that increased plasma prostaglandin E2 levels may be one of the pathogenetic mechanisms responsible for the occurrence of hypercalcemia in this patient.
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Fig. 1
Bone marrow aspiration (A: Wright stain, X1,000) and biopsy (B: H&E stain, X100). Nearly 30% of all hematopoietic cells were immature cells. The bone marrow section was hypocellular (40%) for her age and there were more immature cells than those in the aspirate. Immunophenotypic analysis was positive for CD45 and CD10, but negative for CD3, CD20, CD68, and CD79a. Cytogenetic analysis showed a normal female karyotype (46,XX).
Fig. 2
Multiple osteolytic lesions at diagnosis (A) and after CR (B). At diagnosis, multiple osteolytic lesions were seen in the skull, pelvic bone, both femurs, and both tibias (A), but after CR, the multiple osteolytic lesions were improved, but the osteoporotic change remained (B).
Fig. 3
Simple x-ray and MR image of the left proximal humerus at diagnosis (A) and after CR (B). At diagnosis, a simple X-ray revealed an osteolytic lesion of the left proximal humerus metaphysis. On MR imaging, an ill-defined low-signal intensity mass lesion was noted at the same level of the T1-weighted image coronal scan (A). However, simple x-ray and MR images of this lesion showed improvement after CR (B).
Fig. 4
Whole body bone scan shows overall decreased activities of the growth plates, which were more severe at the left femoral head, right knee, and left humeral head.
Fig. 5
Clinical courses. The elevated calcium level was normalized after supportive care with the initiation of induction chemotherapy.
Table 1.
Laboratory findings at diagnosis and upon complete remission (CR) of ALL
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