Vertebral fracture as an initial manifestation of Acute Lymphoblastic Leukemia: A case series

Introduction/Background/Significance: The skeletal manifestations of Acute Lymphoblastic Leukemia (ALL) usually present as generalized or local bone pain, or joint pain. There are anecdotal reports of vertebral compression fracture as initial presentation of acute lymphoblastic leukemia in pediatrics. Vertebral compression fracture in the adult population is very rare. Here, we are reporting 3 middle-aged patients presented with compression fracture as an initial manifestation of acute lymphoblastic leukemia

Materials and Methods/Case Presentation/Objective: Case 1

A 38-year-old male presented with diffuse chest pain and severe back pain for 4 months. An MRI Spine revealed multiple compression fractures at L1 -L4. A complete blood count (CBC) showed pancytopenia with a WBC of 1840 cells/mm³, Hemoglobin of 9.1 g/dL and Platelet count of 33,000 cells//mm³. A bone marrow biopsy showed Philadelphia negative acute lymphoblastic leukemia. The patient underwent a spine biopsy during kyphoplasty which revealed ALL. A CSF analysis did not reveal any evidence of AL L .Patient's pain gradually got better on chemotherapy. Patient had Ph like ALL and is currently undergoing evaluation for allogeneic stem cell transplantation.

Case 2

A 38-year-old male with no past medical history presented with fatigue and progressive low back pain for 3 months and weight loss. CBC showed severe leukocytosis with WBC count of 115,000cells//mm³ , anemia with Hemoglobin 4.8g/dL, and thrombocytopenia with a platelet count of 6000 cells//mm³.MRI spine revealed a compression fracture at T 11. Bone marrow biopsy confirmed Philadelphia chromosome-positive B-cell acute lymphoblastic leukemia (Ph+ B-ALL) with BCR-ABL1 p190 fusion.He was initially treated with mini HyperCVAD with inotuzumab and rituximab and later transitioned to ponatinib and blinatumomab.A. CSF analysis was negative for ALL. He remains in complete remission on blinatumomab and ponatinib. His compression fracture was managed conservatively.

Case 3

A 57 year old female with a history of lumbar spinal stenosis, chronic pain syndrome presented with complaints of lower back pain for 9 months and weight loss. Complete blood count showed a WBC count of 6700 cells//mm³ Hb of 8.5g/dL and platelet count of 4,58,00 cells//mm³.An MRI showed extensive multifocal lesions involving skull and calvarium and .multiple compression fractures were seen at L1 and L3 vertebral body. Bone marrow biopsy showed 95% involvement of Ph-B -ALL., Based on poor performance status, she was given mini HyperCVAD with Inotuzumab followed by blinatumomab. Her compression fracture was managed conservatively.

Results/Description/Main Outcome Measures: We are reporting three patients who presented with compression fractures, two of whom had upper lumbar, and the other with lower thoracic involvement. Most cases of ALL are usually seen acutely unlike in these cases presenting as chronic back pain. Two of them were managed conservatively while one was treated with kyphoplasty. It is notable to point out that in spite of having spinal involvement, there was no evidence of ALL in the CNS.

Conclusions: Vertebral compression fractures can be a rare initial presentation of ALL. An early recognition especially in people with persistent chronic back pain is essential for diagnosis. Prompt diagnosis and initiation of appropriate chemotherapy can lead to improved outcomes.