1. S Gupta Rheumatology Study day RMCH 10/5/2011

2. Presentation 14 yrs old female 1 st time- 13/3/2011 to A & E Pain in left thigh for 1/7 Xray of left thigh taken Discharged home Represented to the GP- 12/4/11 4/7 pain in lower back and both legs 3/7 h/o fever Started period 4/7 ago

3. Negative H/o Mouth ulcers, hair loss proximal muscle weakness Cough, weight loss, low grade fever Night sweats Foreign travel But was Spiking temps all day last 36 hours

4. Fever pattern

5. Bloods done by GP Hb-12.3, WCC- 4.1, Neut- 2.1, plts- 77, CRP- 198 No h/o foreign travel Pregnancy test –negative Blood film- leucoerythroblastic

6. Under Paeds team at RMCH Seen by Haematologist Given 5/7 of iv Benpen and Fluclox MRI spine done

8. MRI Report Multiple small areas of signal abnormality in several vertebral bodies and possibly in the pelvis. These may represent multifocal osteomyelitis,including the possibility of TB, or other infiltrative process. Clinical correlation is suggested.

9. Differential Infection- Possibly TB osteomyelitis abscess Inflammation Infiltration

10. Further tests Mantoux- negative Quantiferon- negative ESR- 118 LDH- 1065 Low WCC and low platelets Spinal review sought- unlikely discitis

11. Opinion sought from Rheumatologist DD- 1) Malignancy- ALL, Lymphoma, bony metastasis, Neuroblastoma 2) Infection- TB, Salmonella 3) Lupus 4) Chronic multifocal osteomyelitis

12. advice Bone marrow biopsy Urine catecholeamines Ferritin Exclude TB Urgent- ANA, dsDNA, C3, C4, ANCA, IgGs Coombe’s test Bone scan if biospy normal.

13. Bone marrow Infiltrated with population of large blasts Likely acute leukaemia Tranferred to Oncology ward Commencement of chemotherapy Rapid improvement in her symptoms.