Presentation:
Ella, was an 11 year old school student was brought in by her mother, suffering from sudden onset right groin and anterior thigh pain. Ella was a lovely kid who was normally very healthy, so this presentation was highly unusual.
Symptoms:
Ella’s pain was strong, deep and sharp. She could walk with difficulty but was bent forward. The only thing that aggravated her pain was straightening up. This was a startling presentation, especially given the lack of a known etiology.
History:
The symptoms began quickly over a 2-3 day time span. There was no obvious etiology and she had suffered no trauma. She had no prior history of illness. Nothing jumping out here.
She was on no regular medication. Or here.
Examination:
Ella was quite tall for her age and of slim build. She appeared to be in good health and was generally bright with an, up to now, outgoing personality.
It was not possible to examine her standing because she could not stand or sit up straight. Similarly she could not lie prone without sudden lancinating pain from her hip and groin to her knee. The only position in which she could examined was supine. Our normal examination protocol is very extensive, but in this case we could do very few of the normal tests because of the degree of pain she was in and the unusual posture that she was forced to adopt to be relatively comfortable.
Orthopaedic:
Ella could only lie supine with her right leg flexed at the hip, any other position was far too painful.
FABER and FADIR tests were both unremarkable. She was unable to extend the involved leg beyond ~45° without extreme pain. This was the point where my radar was really screaming. I would’ve normally expected this sort of symptom picture to be caused by a slipped epiphysis or labral tear; both of which would have fired off a positive FABER or FADIR.
Neither test produced any pain until I tried to straighten her leg beyond ~45° and then the exacerbation was spectacular.
Abdominal palpation revealed a soft abdomen, with normal bowel sounds. The lower right quadrant was very tender to light pressure. There was no rebound tenderness and she did not have a fever. Nothing to indicate appendicitis apart from the focal tenderness in the lower right quadrant. Even LRQ pain is not necessarily indicative of appendicitis in a younger patient – it can be epigastric.
Neurological Examination:
All cranial nerves tests were normal and bilaterally equal. She could not stand or sit upright so I couldn’t do all of the usual Neuro/Ortho tests that I’d do (which is a lot!) My normal examination always includes cranial nerves, but can also involve anywhere from 60-80 different tests – I just couldn’t do many with her. Cranials and limb reflexes were all I could test.
As far as could be tested, the lower limb neurology was all normal.
What Is Your Provisional Diagnosis?
My Provisional Diagnosis at that stage was Psoas Abscess because Ella was showing a glaring Obraztsova’s (Cope’s) sign, which is often associated with Appendicitis (no other confirming signs) or Psoas Abscess. It has a Sensitivity of 13%-42% and Specificity of 79%-97% but does not differentiate between the two possible etiologies.
If You Have A Differential Diagnosis or Diagnoses, What Is It (or They)?
My first Differential Diagnosis was Appendicitis but was held in abeyance because other confirming signs (fever, vomiting, diarrhea, abdominal rigidity, quiet abdomen,) were absent.
Ella had shown no signs of the onset of puberty so, while an Ovarian Cyst was possible it was not considered a likely cause. The location of the pain in the groin rather than in the lower abdomen also didn’t bring the OC to front of the list.
What Further Tests (if any) Would You Do?
We sent Ella directly to her GP to order a full blood screen.
All tests were normal with the exception of:
Globulin: 46g/l (Ref. Range: 22-40)
Ferritin: 378µg/l (Ref. Range: 10-150)
RDW: 18.6% (Ref. Range: 11.1-16.0)
Monocytes: 21% (Ref. Range: 0-1)
The Pathologist’s conclusion was:
“Mild monocytosis with increased rouleaux in a child, most likely in keeping with infection or inflammation.”
We were not convinced and therefore asked the GP to refer Ella for an ultrasound in an attempt to get eyes on whatever was there. This revealed a chain of enlarged nodes in the pelvic bowl, particularly involving the Common Iliac chain on the right.
Ella was immediately referred to a Pediatric Oncologist who, after an MRI, PET scan and biopsy was able to confirm a diagnosis of Anaplastic Large Cell Lymphoma.
Ella’s presenting symptoms were caused by the inflammation of the Iliac nodes spreading to the psoas. She underwent a long course of chemotherapy, immunotherapy and radiation therapy which resulted in complete recovery.
But the story does not end here…..
In November 2019 Ella once again presented to her Pediatric Oncologist complaining of the same symptoms…..right groin pain extending down the anterior thigh to the knee. He could find no reason for the pain.
On the assumption that the pain was of neurological origin, he prescribed both Gabapentin and Lyrica. Apart from some very unpleasant side-effects (drowsiness, dizziness, fatigue and mood swings) there was no change in Ella’s symptoms. She could not tolerate the side effects and stopped the medication.
In January 2021 she was referred for an MRI which revealed the following…
CLINICAL INDICATION:
Past HX of ALCL. Right groin. Off treatment. Ongoing right hip and anterior thigh pain.
FINDINGS:
Previous abdomen/pelvic MRI of 5/9/2019 was reviewed.
Low-grade oedema signal seen in the right trochanteric bursa.
Mild bilateral oedema is noted in the quadratus femoris muscles.
The hip joint is unremarkable, with no effusion, normal femoroacetabular chondral surfaces, normal labrum and normal ligamentum teres.
No abnormality of the adductors, iliopsoas, rectus femoris, sartorius or tensor fascia lata, gluteal muscles and tendons are within normal limits. Hamstring origin within normal limits.
No marrow signal abnormality.
Florid pelvic venous collateralisation/engorgement again demonstrated, in keeping with prior pelvic DVT.
This is most prominent in the right pelvic side wall and parametrial veins.
CONCLUSION:
No abnormality of the right hip seen.
Mild oedema in the right trochanteric bursa. Correlation with focal tenderness in this region is suggested
She was then referred to a Physiotherapist who diagnosed Meralgia Paresthetica. She was treated with massage and stretching but this too made no difference. The Physiotherapist then referred her to me.
On examination there was still some tenderness in the right groin and LRQ. Other than that she had her usual array of biomechanical issues. I adjusted her regularly over the next three years and while the symptoms reduced markedly, they never quite cleared.
Over that three year period on three separate occasions I had noticed and brought to her attention suspicious looking moles – all of which turned out to be melanomas. Thankfully she was very diligent in having them removed immediately. Some people just seem to have the “cancer gene”!
Ella grew into a delightful young lady and we remain in contact.
About now, you’re probably wondering what the point is of this closing section. The answer lies in these two sentences from the MRI report:
“Florid pelvic venous collateralisation/engorgement again demonstrated, in keeping with prior pelvic DVT.
This is most prominent in the right pelvic side wall and parametrial veins.”
It’s extremely likely that the recurrence of Ella’s symptoms was due to Pelvic Congestion Syndrome secondary to the inflammation and radiotherapy she endured in dealing with the ALCL.
Is This A Chiropractic Case?
No, but YES!
It’s not a Chiropractic case in that Ella’s immediate and life threatening cancer could not be directly helped with adjustments.
However, as Doctors of Chiropractic we have a responsibility that goes beyond simply adjusting subluxations. The “Dr” that we’re all so proud to wear in front of our names comes with an enormous responsibility. It is within our imprimature to care for our patients’ health, and not only those parts that we like to manage with our own skill set. It includes ALL of it!
Clearly we can’t administer chemo or perform surgery, but we CAN ensure that we know enough to be a major and useful part of our patients health care team. We can ensure that we know enough to raise the flag when we find something sinister, like a lump or a suspicious spot; enough to be able refer for and read an MRI or to understand what we’re looking at on a blood test.
If we do our job properly we will soon find that, like it or not, we very quickly become “the person most trusted” for our patients. We become their first port-of-call, the person they come to for answers when an explanation is not forthcoming from another member of the health care team, or that information seems like gobbledygook.
So YES, within the appropriate realms, and for the appropriate reasons, this case, like so many others IS a Chiropractic Case. Because we’re Doctors of Chiropractic.
At this point I’d like to thank those Doctors who responded when this case was first sent out. Your answers were extraordinarily good, well reasoned and clearly followed. beautifully rational diagnostic logic.
We have some very, very bright people amongst us.
Stay tuned for further cases soon,
Dr Rob
