Leukaemic synovitis
Department of Rheumatology, St Vincent's University Hospital, Dublin, Ireland
Correspondence to: Michalis Voulgarelis, MD, University of Athens Medical School, Department of Pathophysiology, 75 M. Asias Street, 11527, Athens, Greece. E-mail: mvoulgar{at}med.uoa.gr
A 75-yr-old female, previously diagnosed as myelodysplastic syndrome, presented with fever, migratory polyarthritis and pancytopenia. Physical examination revealed frank symmetrical arthritis, additive in character that involved knees and ankles. The examination of peripheral blood film did not disclose blast cells. Synovial fluid analysis showed a leucocyte count of 70 000/mm3 (predominantly neutrophils), while the examination for micro-organisms on Gram stain and for crystals with a polarizing microscope was negative. Radiographs of involved joints demonstrated only soft-tissue swelling. Intravenous antibiotics were empirically initiated without improvement. Synovial fluid cytocentrifugation stained by May-Grunwald & Giemsa (Fig. 1), revealed the presence of a large number of agranular blast cells with evenly distributed nuclear chromatin, irregular nuclei with single nucleolus and occasional cytoplasmic vacuolation suggesting leukaemic synovial infiltration. Myelodysplasia-associated abnormalities such as binuclear erythroblasts, pseudo-Pelger neutrophils and non-sex-specific drumstick-like nuclear appendage coexisted. Bone marrow examination established the diagnosis of acute myelomonocytic leukaemia, demonstrating that leukaemic synovitis may be the initial manifestation of acute leukaemia. Chemotherapy with low-dose cytarabine controlled the articular symptoms.
|
The musculoskeletal manifestations of leukaemia include symmetric or migratory polyarthritis or arthralgias, bone pain and tenderness and back pain, mimicking a radiculopathy secondary to meningeal involvement. Approximately 4% of the adults with leukaemia have articular manifestations, and approximately 14% of children and, in some series, 13.5% of patients overall have articular symptoms as presenting features of leukaemia. Leukaemic joint manifestations may be the result of leukaemic synovial infiltration, hemorrhage into the joint or periarticular structures, crystal-induced synovitis, or synovial reaction to adjacent bony, periosteal or capsular lesions. Leukaemic synovitis may be the initial manifestation of relapse, even if not present at the time of initial diagnosis of leukaemia. Leukaemic arthritis may be pauci or polyarticular with a predilection for larger joints, with pain being disproportionate to physical findings. Any synovial fluid cell count can be consistent with a diagnosis of leukaemia-associated arthritis. Blast cells are uncommonly found in the synovial fluid, and synovial biopsies may miss a focus of myeloblast cells. Use of a technique involving immunofluorescence and a panel of early B-cell and myeloid antigens may increase the yield of identifying leukaemic cells in synovial effusion and biopsy. Treatment of the underlying leukaemia may relieve bone and joint symptoms and may indicate efficacy of the therapy for leukaemia. Adjunctive radiation therapy to affected joints may be necessary to control symptoms.
The authors have declared no conflicts of interest.
CiteULike 
Connotea 
Del.icio.us What's this?
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||