Background: Acute lymphoblastic leukaemia (ALL) is the most common form of paediatric cancer. Despite this, nonspecific symptoms are common and only high levels of suspicion lead to diagnosis. Prompt diagnosis leads to early intervention and better outcome. This can pose a key challenge in clinical practice. Case: A 4-year-old boy presented with left-sided dull neck pain on lateral flexion to the right without a traumatic history. Upon further questioning, it was noted he had been getting night sweats in the last few months. Examinations revealed a single tender cervical lymph node on the left lateral neck. Investigations showed neutropenia, leukopenia, low haematocrit and elevated ferritin. Haemoglobin was on the lower extreme of the reference interval, and LDH at higher extreme of reference interval. Ultrasound showed an enlarged but normal appearing lymph node. These non-specific findings raised suspicion, so the local paediatric team was contacted. Subsequent lymphocyte subsets revealed an elevated blast population. Definitive diagnosis of ALL was made with bone marrow biopsy and chemotherapy was commenced immediately.
Discussion: Symptoms of ALL such as malaise, bruising and bone pain are often not present on initial history. This extends to examination findings of fever and organomegaly. Clinicians should therefore be vigilant and act on suspicious clinicals signs early by taking a broad history and examination. Having pathology results within the normal reference intervals can be misleading so they should be interpreted as a whole to lead to a pathogenic pattern. Implications for practice: Malignancy is an uncommon presentation in the paediatric setting but one that clinicians should not miss. This case reiterates that clinicians should maintain a high level of suspicion, particularly when investigation findings are at extreme ends of reference intervals. Importance should be placed on red-flag B symptoms. Urgent direct communication with the local paediatric team is essential in escalating patient care.