第459例——关节痛、发热、皮疹、血小板下降

The 459th case：arthralgia, fever, rash, and thrombocytopenia

对原因不明的骨关节痛症状,尤其不能用当前疾病解释全貌时,要考虑到其他疾病所致反应性关节炎甚至急性白血病的可能,勿忽视骨髓穿刺适应证.本例患者50岁,女性,以关节痛起病,反复发热,病程中出现皮疹,曾先后或同时出现轻度白细胞下降、贫血、血小板下降及淋巴细胞比例升高,诊断结缔组织病并应用糖皮质激素治疗后血象恢复正常.9个月后血小板骤然下降,经骨髓细胞形态学、流式细胞术、染色体检查后最终确诊为急性淋巴细胞白血病.提示部分白血病在诊治过程中需要不断评估诊断的准确性并及时修正,避免思维局限、惯性思维.

[The differential diagnoses of reactive arthritis presenting as arthralgia should be considered as diverse disorders , especially when the symptoms cannot be fully explained by some definite diseases.Do not ignore the indication of bone marrow aspiration .We reported a 50-year-old woman who complained of arthralgia , recurrent fever and rash 9 months ago.Laboratory exams showed mild leukopenia , anemia, thrombocytopenia and increased lymphocyte proportion .She was treated with glucocorticoid after the diagnosis of connective tissue disease was suspected .Until platelet count abruptly decreased to very low level, the final diagnosis of acute lymphoblastic leukemia was made through bone marrow morphology , flow cytometry, and chromosome examination .Therefore, a small number of leukemia is not easily diagnosed by routine operations .Thus when diagnoses are not determined with recurrent symptoms , cautious observation and further examination are required to avoid misdiagnoses or missed diagnoses of acute leukemia .