DD:backpain2

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Template:Back pain2 the differentials of back pain lasting for > 6 weeks despite conservative therapy,elevated ESR, elevated CRP, weight loss in a patient with age > 50 years, a history of immunosupression, chronic steroid use, intravenous drug use include the following:

Classification of pain in the back based on etiology Diease Clinical Manifestation Diagnosis Comments
Symptoms Signs Lab findings Imaging
Onset Duration Quality of pain Radiation Stiffness Fever Rigors and chills Headache Nausea and vomiting Syncopy Weight loss Motor weakness Sensory deficit Pulse Deficit Heart Murmur Bowel or bladder dysfunction Horner's syndrome
Tumors Ewing's sarcoma[1][2][3] Chronic Months to years Dull aching Variable +/- +/- +/- - - - + - - - - - -

Tests are used to rule out other pathologies; CBC

  • May indicate anemia

Blood cultures

  • May be positive for various organisms

ESR and CRP

  • May be elvated

LDH

  • May be elevated

Cytogenetic studies

  • May be positive for t(11;22) translocation

Immunohistochemical markers

  • May be positive for MIC2 antigen (CD99)
 Radiography
  • Periosteal reaction "onion skin"
  • Cortical thinning
  • Mottling

MRI

  • Skip lesions
  • Edema
  • Metastasis

PET - FDG

  • To identify metastatic disease
Langerhans cell histiocytosis[4][5][6][6](eosinophilic granulomas) Chronic Months to years Dull aching Variable - +/- +/- - - - - - - - - - - Tests used to rule out other pathologies;

CBC

  • Reticulocyte count may be increased
  • Positive or negative direct and indirect Coombs test
  • Immunoglobulin levels may be elevated

ESR

  • May be elevated

LFT

  • May demonstrate elevations in total protein, albumin, alanine aminotransferase, aspartate aminotransferase, alkaline phosphatase, and gamma-glutamyltransferase
  • Elevations may mean liver cirrhosis

Urine analysis

  • Decrease in urine osmolality may indicate diabetes insipidus
 Radiography
  • Single or multiple osteolytic lesions may be noted

CT

  • To identify abnormalities of the hypothalamic and/or pituitary region

MRI

  • To identify abnormalities of the hypothalamic and/or pituitary region

PET - FDG

  • More sensitive than CT or MRI to active disease
Leukemia[7][8][9][10] Acute or chronic Weeks to years Aching Variable - +/- +/- - - - + - - - - - - CBC
  • Mature or immature leukocytosis

Coagulation study

  • May demonstrate elevated prothrombin time, decreasing fibrinogen level, and presence of fibrin split products

Peripheral blood smear

  • May demonstrate blasts, schistocytes, auer rods, and mature lymphocytosis

Blood chemistry profile

  • May demonstrate tumor lysis syndrome through elevated LDH and uric acid

Blood culture

  • To rule out infection
  • Typically no routine imaging studies, cytogenetic and flow cytometries aid diagnosis
  • Acute and chronic, lymphocytic and myeloid diagnoses are based on the presence and type of blast or mature cell
Lymphoma[11][12][13][14] Chronic Months to years Aching Variable - +/- +/- - - - + - - - - - - Typically no specific lab findings, however, the following routine tests are performed;
  • CBC
  • Serum chemistry studies, including LDH
  • Serum beta2-microglobulin level
  • HIV serology
 Radiography
  • May demonstrate hilar or mediastinal adenopathy
  • Pleural or pericardial effusion
  • Parenchymal involvement
  • Bulky mediastinal mass

CT

  • May demonstrate enlarged lymph nodes
  • Hepatosplenomegaly
  • Filling defects in visceral organs

Bone scan

  • Useful in those with elevated alkaline phosphatase

Gallium scan

  • May show increased uptake

MRI

  • Signal intensity changes are noted in those with bone marrow or muscular involvement

PET - FDG

  • To distinguish between viable, active tumors and necrosis
  • To detect early recurrence

Ultrasound

  • Useful if primary lesion is in testis
  • Hodgkin's lymphoma is usually focal and characterized by Reed-sternberg cells
  • Non - hodgkin's lymphoma tends to be multifocal
  • Biopsy provides ultimate diagnosis
Neurofibroma[15] Chronic[16][17] Weeks to years Aching, pressure Variable - - - - - - - - - - - - - Molecular sequencing
  • Used to detect neurofibromin gene

Urine analysis

  • Used to detect free catecholamine and their metabolites in suspected pheochromocytoma
 Radiography
  • Bowing of bones
  • Medullary destruction

MRI and CT

  • Used to determine neurologic pathologies
  • May demonstrate unidentified bright objects in brain scans
  • May demonstrate optic nerve and optic chiasma involvement
  • Bilateral acoustic neuroma is noted in neurofibromatosis type 2

PET - FDG

  • Used to determine staging
  • Marfanoid habitus may be noted in neurfibromatosis type 1
Osteoblastoma[18][19][20] Chronic Weeks to years Dul aching Variable - - - - - - - - - - - - -
  • Typically no specific lab findings are noted
 Radiography
  • May demonstrate a well-circumscribed radiolucent tumor in cortex
  • Thin shell of peripheral new bone distinct from soft tissue
  • > 2cm in diameter
  • No associated reactive zone

CT and MRI

  • May demonstrate size and extent of tumor relative to surrounding soft tissue

Bone scan

  • Demonstrates cortical activity within the bone

Angiography

  • Demonstrates the vascularity of the tumor
  • Presents in third decade of life
  • Pain is not relieved by NSAIDs
Osteoid osteoma[21][22][18] Chronic Years Dull aching Variable - - - - - - - - - - - - - Serum chemistry study
  • High levels of prostaglandin metaboliteshave been linked with osteoid osteomas
 Radiography
  • May demonstrate sclerosis around a radiolucent nidus

CT

  • Demonstrates the margins of the nidus and calcifications present

MRI

  • Useful only in a non-calcified nidus

Radionuclide scan

  • Demonstrates increased uptake in diseased bone

Arteriography

  • Used a last resort when other imaging has been unfruitful
  • Demonstrates 2 phases, early arterial phase, late arterial phase and venous phase
  • Pain is relieved by use of NSAIDs
Osteosarcoma[23][24][25][26] Chronic Weeks to years Severe, sharp Variable - - - - - - - - - - - - -
  • Typically no specific lab findings
  • Elevated LDH and alkaline phosphatase may suggest pulmonary metastasis

Radiography

  • May demonstrate an osteolytic or osteoblastic lesion
  • Elevation of the periosteum may be noted, and is known as "Codman's triangle"
  • Tumor spread to periosteum is known as "sunburst" sign

CT

  • Chest CT is done to rule out pulmonary involvement
  • May also demonstrate the margins and extent of tumor

MRI

  • Useful in detection of soft tissue involvement

Bone scan

  • Increased uptake is noted in regions of metastasis
  • Technetium-99 - methylene diphosphonate is usually used
  • Cardiac function should be assessed before the use of doxorubicin or daunorubicin
Multiple myeloma[27][28] Chronic Years Dull aching Hips, groin and legs +/- +/- +/- - - - +/- - - - - +/- - Serum protein electrophoresis
  • May demonstrate a M peak

Serum free light chain assay and 24 - hour urine collection

  • May detect Bence-Jones proteins

CRP

  • May be elevated

Serum beta2-microglobulin

  • May be elevated

Albumin

  • May demonstrate elevated albumin in urine

LDH

  • May be elevated

Peripheral blood smear

  • May demonstrate rouleaux formation > 50%
  • Leukopenia
  • Thrombocytopenia
 Radiography, MRI and PET
  • Osteolytic lesions may be demonstrated
  • Biopsy will demonstrate elevated plasma cells in the bone marrow
Prostate cancer[29][30] Chronic Months to years Severe, sharp Lower abdomen, hips, groin and legs - +/- +/- - - - +/- - - - - - - PSA
  • Detection is helpful in diagnosis, usually > 10 ng/ml

Acid and alkaline phosphtase

  • Useful in detecting metasstasis

Serurm creatinine and LFT

  • Useful in detecting metasstasis

Urine analysis

  • May detect hematuria or infection
 Ultrasound
  • Transrectal biopsy transrectal ultrasound may demonstrate hypoechoicity

MRI

  • May be used to guide biopsy
  • PSA and DRE are gold standard for screening
Vertebral osteomyelitis[31][32][33] Acute Minutes to hours Sudden, severe, sharp Shoulders, arms, hips and legs +/- + +/- - +/- - - +/- +/- - - +/- - CBC
  • Leukocytosis and left shift

ESR

  • Elevated

CRP

  • Elevated

Procalcitonin

  • Elevated

Culture and sensitivity

  • To identify causative agent
 Radiography
  • Demonstrates endosteal or medullary lesion
  • Sequestration and cavity formation

MRI

  • Bone marrow abnormalities and lytic changes

CT

  • Articular and periarticular involvement

Ultrasound

  • Soft tissue abnormalities

Nuclear imaging

  • Loss of bone density
  • Often caused by hematogenous spread of organism
  1. ↑ Cotterill SJ, Ahrens S, Paulussen M, Jürgens HF, Voûte PA, Gadner H, Craft AW (September 2000). "Prognostic factors in Ewing's tumor of bone: analysis of 975 patients from the European Intergroup Cooperative Ewing's Sarcoma Study Group". J. Clin. Oncol. 18 (17): 3108–14. doi:10.1200/JCO.2000.18.17.3108. PMID 10963639.
  2. ↑ Nesbit ME, Gehan EA, Burgert EO, Vietti TJ, Cangir A, Tefft M, Evans R, Thomas P, Askin FB, Kissane JM (October 1990). "Multimodal therapy for the management of primary, nonmetastatic Ewing's sarcoma of bone: a long-term follow-up of the First Intergroup study". J. Clin. Oncol. 8 (10): 1664–74. doi:10.1200/JCO.1990.8.10.1664. PMID 2213103.
  3. ↑ Raney RB, Asmar L, Newton WA, Bagwell C, Breneman JC, Crist W, Gehan EA, Webber B, Wharam M, Wiener ES, Anderson JR, Maurer HM (February 1997). "Ewing's sarcoma of soft tissues in childhood: a report from the Intergroup Rhabdomyosarcoma Study, 1972 to 1991". J. Clin. Oncol. 15 (2): 574–82. doi:10.1200/JCO.1997.15.2.574. PMID 9053479.
  4. ↑ Grois N, Pötschger U, Prosch H, Minkov M, Arico M, Braier J, Henter JI, Janka-Schaub G, Ladisch S, Ritter J, Steiner M, Unger E, Gadner H (February 2006). "Risk factors for diabetes insipidus in langerhans cell histiocytosis". Pediatr Blood Cancer. 46 (2): 228–33. doi:10.1002/pbc.20425. PMID 16047354.
  5. ↑ Baumgartner I, von Hochstetter A, Baumert B, Luetolf U, Follath F (January 1997). "Langerhans'-cell histiocytosis in adults". Med. Pediatr. Oncol. 28 (1): 9–14. PMID 8950330.
  6. ↑ 6.0 6.1 Malpas JS, Norton AJ (December 1996). "Langerhans cell histiocytosis in the adult". Med. Pediatr. Oncol. 27 (6): 540–6. doi:10.1002/(SICI)1096-911X(199612)27:6<540::AID-MPO6>3.0.CO;2-L. PMID 8888814.
  7. ↑ Clarke RT, Van den Bruel A, Bankhead C, Mitchell CD, Phillips B, Thompson MJ (October 2016). "Clinical presentation of childhood leukaemia: a systematic review and meta-analysis". Arch. Dis. Child. 101 (10): 894–901. doi:10.1136/archdischild-2016-311251. PMID 27647842.
  8. ↑ Konopka JB, Witte ON (November 1985). "Detection of c-abl tyrosine kinase activity in vitro permits direct comparison of normal and altered abl gene products". Mol. Cell. Biol. 5 (11): 3116–23. PMC 369126. PMID 3879812.
  9. ↑ Siegel RL, Miller KD, Jemal A (January 2017). "Cancer Statistics, 2017". CA Cancer J Clin. 67 (1): 7–30. doi:10.3322/caac.21387. PMID 28055103.
  10. ↑ Faderl S, Talpaz M, Estrov Z, O'Brien S, Kurzrock R, Kantarjian HM (July 1999). "The biology of chronic myeloid leukemia". N. Engl. J. Med. 341 (3): 164–72. doi:10.1056/NEJM199907153410306. PMID 10403855.
  11. ↑ Anderson T, Chabner BA, Young RC, Berard CW, Garvin AJ, Simon RM, DeVita VT (December 1982). "Malignant lymphoma. 1. The histology and staging of 473 patients at the National Cancer Institute". Cancer. 50 (12): 2699–707. PMID 7139563.
  12. ↑ Mohren M, Markmann I, Jentsch-Ullrich K, Koenigsmann M, Lutze G, Franke A (April 2005). "Increased risk of thromboembolism in patients with malignant lymphoma: a single-centre analysis". Br. J. Cancer. 92 (8): 1349–51. doi:10.1038/sj.bjc.6602504. PMID 15798767.
  13. ↑ Cozen W, Katz J, Mack TM (1992). "Risk patterns of Hodgkin's disease in Los Angeles vary by cell type". Cancer Epidemiol. Biomarkers Prev. 1 (4): 261–8. PMID 1303125.
  14. ↑ Bazzeh F, Rihani R, Howard S, Sultan I (December 2010). "Comparing adult and pediatric Hodgkin lymphoma in the Surveillance, Epidemiology and End Results Program, 1988-2005: an analysis of 21 734 cases". Leuk. Lymphoma. 51 (12): 2198–207. doi:10.3109/10428194.2010.525724. PMID 21054151.
  15. ↑ Banik R, Lubach D (1987). "Skin tags: localization and frequencies according to sex and age". Dermatologica. 174 (4): 180–3. PMID 3582706.
  16. ↑ Campbell LB, Petrick MG (March 2007). "Mohs micrographic surgery for a problematic infantile digital fibroma". Dermatol Surg. 33 (3): 385–7. doi:10.1111/j.1524-4725.2007.33080.x. PMID 17338704.
  17. ↑ Requena L, Fariña MC, Fuente C, Piqué E, Olivares M, Martín L, Sánchez Yus E (May 1994). "Giant dermatofibroma. A little-known clinical variant of dermatofibroma". J. Am. Acad. Dermatol. 30 (5 Pt 1): 714–8. PMID 8176009.
  18. ↑ 18.0 18.1 Copley L, Dormans JP (August 1996). "Benign pediatric bone tumors. Evaluation and treatment". Pediatr. Clin. North Am. 43 (4): 949–66. PMID 8692589.
  19. ↑ Greenspan A (October 1993). "Benign bone-forming lesions: osteoma, osteoid osteoma, and osteoblastoma. Clinical, imaging, pathologic, and differential considerations". Skeletal Radiol. 22 (7): 485–500. PMID 8272884.
  20. ↑ Boriani S, Capanna R, Donati D, Levine A, Picci P, Savini R (May 1992). "Osteoblastoma of the spine". Clin. Orthop. Relat. Res. (278): 37–45. PMID 1563167.
  21. ↑ Orlowski JP, Mercer RD (April 1977). "Osteoid osteoma in children and young adults". Pediatrics. 59 (4): 526–32. PMID 850593.
  22. ↑ Wyers MR (April 2010). "Evaluation of pediatric bone lesions". Pediatr Radiol. 40 (4): 468–73. doi:10.1007/s00247-010-1547-4. PMID 20225104.
  23. ↑ Mialou V, Philip T, Kalifa C, Perol D, Gentet JC, Marec-Berard P, Pacquement H, Chastagner P, Defaschelles AS, Hartmann O (September 2005). "Metastatic osteosarcoma at diagnosis: prognostic factors and long-term outcome--the French pediatric experience". Cancer. 104 (5): 1100–9. doi:10.1002/cncr.21263. PMID 16015627.
  24. ↑ Sissons HA (1976). "The WHO classification of bone tumors". Recent Results Cancer Res. (54): 104–8. PMID 1070715.
  25. ↑ CADE S (December 1955). "Osteogenic sarcoma; a study based on 133 patients". J R Coll Surg Edinb. 1 (2): 79–111. PMID 13307660.
  26. ↑ Dahlin DC, Unni KK (March 1977). "Osteosarcoma of bone and its important recognizable varieties". Am. J. Surg. Pathol. 1 (1): 61–72. PMID 203202.
  27. ↑ Kyle RA, Gertz MA, Witzig TE, Lust JA, Lacy MQ, Dispenzieri A, Fonseca R, Rajkumar SV, Offord JR, Larson DR, Plevak ME, Therneau TM, Greipp PR (January 2003). "Review of 1027 patients with newly diagnosed multiple myeloma". Mayo Clin. Proc. 78 (1): 21–33. doi:10.4065/78.1.21. PMID 12528874.
  28. ↑ Turesson I, Velez R, Kristinsson SY, Landgren O (March 2010). "Patterns of multiple myeloma during the past 5 decades: stable incidence rates for all age groups in the population but rapidly changing age distribution in the clinic". Mayo Clin. Proc. 85 (3): 225–30. doi:10.4065/mcp.2009.0426. PMC 2843108. PMID 20194150.
  29. ↑ Porta M, Fabregat X, Malats N, Guarner L, Carrato A, de Miguel A, Ruiz L, Jariod M, Costafreda S, Coll S, Alguacil J, Corominas JM, Solà R, Salas A, Real FX (June 2005). "Exocrine pancreatic cancer: symptoms at presentation and their relation to tumour site and stage". Clin Transl Oncol. 7 (5): 189–97. PMID 15960930.
  30. ↑ Crawford ED, Schutz MJ, Clejan S, Drago J, Resnick MI, Chodak GW, Gomella LG, Austenfeld M, Stone NN, Miles BJ (1992). "The effect of digital rectal examination on prostate-specific antigen levels". JAMA. 267 (16): 2227–8. PMID 1372943.
  31. ↑ Beronius M, Bergman B, Andersson R (2001). "Vertebral osteomyelitis in Göteborg, Sweden: a retrospective study of patients during 1990-95". Scand. J. Infect. Dis. 33 (7): 527–32. PMID 11515764.
  32. ↑ Digby JM, Kersley JB (February 1979). "Pyogenic non-tuberculous spinal infection: an analysis of thirty cases". J Bone Joint Surg Br. 61 (1): 47–55. PMID 370121.
  33. ↑ McHenry MC, Rehm SJ, Krajewski LP, Duchesneau PM, Levin HS, Steinmuller DR (1991). "Vertebral osteomyelitis and aortic lesions: case report and review". Rev. Infect. Dis. 13 (6): 1184–94. PMID 1775852.
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