Severe hypercalcemia and osteolytic lesions in a child. The importance of autopsy.

Pablo Pérez Alonso, Lucía Pérez Gallego, Jorge Calvo de Mora, and Ignacio Rodríguez.

Department of Pathology. University Hospital "La Paz". Madrid. Spain.

Address: Paseo de la Castellana, 261.
28046 Madrid. Spain

[Introduction] [Materials & Methods] [Results] [Pictures] [Discussion] [Bibliography]

Summary

We preset a 9 years old boy suffering from back pain at dorso-lumbar region during the last three months and disseminated petechiae. The analytical studies revealed sever hypercalcemia (22 mg/dl) and the radiological examination showed multiples lytic images in vertebrae, ribs and innominate bone. In the hematological study there was leukocytosis without blasts (LUC 2.2 %), trombopenia, and the cell population in bone marrow aspirate was normal, without any blast cell.

These findings lead to the possibility of bone metastasis from a tumor of unknown origin. Thirty six hours after admittance he dies because of acute pulmonary edema and progressive shock. The postmortem radiological study confirmed the lytic lesions in vertebrae and ribs, and also in the skull. These lesions corresponded to a lymphoproliferative process of blast cells type B.

Hypercalcemia is an unusual complication in malignant tumors in childhood. In large series, it is only present in 25 of 6,055 tumors in children (0.4 %). From these, 3,239 were solid tumors and 2,816 acute leukemias and lymphomas (1); Amongst the 25 neoplasias that presented with hypercalcemia, 11 were acute leukemias, 4 rhabdomyosarcomas, 2 rhabdoid tumors, 1 Hodgkin's disease, 1 non-Hodgkin lymphoma, 2 hepatoblastomas, 1 neuroblastoma, 1 cerebral tumor, 1 angiosarcoma, and one non-classified solid tumor. Acute lymphoblastic leukemia (LLA) is the neoplasia that presents more frequently with hypercalcemia at the time of diagnosis. LLA may debut as severe hypercalcemia (1,2), bone lesions and absence of blasts in peripheral blood (3), so that diagnosis may be difficult, as it was in our case.

The autopsy study in these case was essential in order to establish the tumoral etiology of the hypercalcemia and it illustrates the importance of the role that autopsy still plays in a correct final diagnosis.

(1)McKay C,Furman WL. Hypercalcemia complicating childhood malignancies. Cancer 1993;72:256-60.
(2)Harutsumi M y cols. A case of acute lymphoblastic leukemia accompanied with the production of parathyroid hormone-related protein.Miner-Electrolyte-Metab. 1995;21(1-3): 171-6
(3)Soni PN. Hypercalcemia and multiple osteolytic lesions in childhood acute lymphoblastic leukemia. Postgrad-Med-J. 1993 Jun; 69(812): 483-5.

Pablo Pérez Alonso MD, Lucía Pérez Gallego MD, and Jorge Calvo de Mora MD are resident pathologists; José Ignacio Rodríguez is head of the Pediatric Pathology section at Hospital La Paz. Madrid. Spain.

Palabras Claves: Autopsy, Hypercalcemia, Acute lymphoblastic Leukemia

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