A 7-year-old girl with hip pain and leg weakness

Abstract

A 7-year-old girl was admitted to another hospital with paraplegia and a 6-month history of hip pain and progressive weakness and numbness of the lower extremities. This was then diagnosed as rheumatic disease and treated with penicillin. Magnetic resonance imaging (MRI) revealed an extradural mass between the L3 and L5 vertebral bodies. On T2-weighted images, a high signal intensity was noted at L4, suggesting a bone tumor originating in the vertebral body (Fig. 1). Decompressive laminectomy was performed. The post-operative period was uneventful, with clear motor de®cit recovery of the lower extremities.Histological examination showed an in¯ammatory process with no diagnostic characteristics. The child was then referred to our hospital. On admission, she was in fairly good general conditions, with a fever but no evidence of an infectious focus. Laboratory blood examinations showed only moderate hypochromic anemia, while the erythrocyte sedimentation rate and C-reactive protein levels were high. Bone scintigraphy showed two areas of increased uptake on L4 and on the left iliac bone. A computed tomography (CT) scan of the lumbar column carried out to check the status after laminectomy and extended to the pelvic bones revealed an osteolytic process of the left iliac bone with adjacent soft-tissue mass (Fig. 2). A biopsy was performed on this area.The diagnosis was a nodular sclerosing variant of osseous Hodgkin lymphoma. Review of the material obtained by laminectomy con®rmed this.Staging procedures (abdominal and chest CT scans, abdominal ultrasound and bone marrow biopsy) ruled out other sites of disease, and the diagnosis became stage 4B Hodgkin lymphoma (HL) solely aecting the skeletal system (vertebra L4 and left iliac bone). Six weeks after laminectomy, we started chemotherapy with COPP/ABVD [2]. On the whole, the therapy was well tolerated, and after 5 courses of chemotherapy, imaging revealed the disappearance of soft-tissue masses and a healing process of the iliac bone.Radiotherapy (2960 cGy over 16 fractions) was then delivered to the lumbar vertebrae (L3±5) and left iliac bone.One year later, the patient is fully ambulatory, and physical examination is normal. Follow-up imaging is stable. DiscussionBenign or functional diseases such as discopathies, which are frequently seen in adults, have never been reported in children or adolescents. Therefore, in cases of repeated back pain, particularly if associated with limping and diculty in walking, a speci®c work-up is mandatory and urgent. Investigation must be extensive, not only at the site of pain but also throughout the whole body to determine where the biopsy should be carried out, and whenever possible, aggressive approaches such as laminectomy should be avoided.Clinical evidence of spinal cord compression in children with newly diagnosed tumors is a rather uncommon event. Neuroblastoma and Ewing sarcoma are most often involved, but the dierential diagnosis also includes non-Hodgkin lymphomas, leukemia, metastatic lesions, Langerhans cell histiocytosi...