girl with neck pain

Six year old girl child presented with difficulty in turning neck for last two months.Movement of neck in all directions were painful , and was progressively increasing. 

Occasional low grade fever,which was controlled with paracetamol.
No neck  swelling or swelling elsewhere noticed by parents.
No history of trauma 
No history of bone or joint pain elsewhere .
No skin rashes or bleeds.
No past history of significant illness . 
No contact with tuberculosis. 

Immunized update

She was pale  No lymph node enlargement . 

No bleeding manifestations
 Movement of neck restricted in all directions and torticollis present 

She does nt have any swelling or pain on any othe bony points

Abdomen exam
No hepato splenomegaly 

We did a neurological examination ............Normal . 

IMAGINGS 

Xray Neck lateral view 

First look it may be passed of as normal . But few abnormalities 

Common mistakes in interpretation of Xray neck ( both lateral and PA ) 
1. Missing abnormalities in the lowest cervial vertebra. If not taken properly the shoulder shadow may mask the vertebra
2. Missing features of Axis and atlas and the relation 
Before looking at the bodies try to draw a line along anterior posterior margin of bodies. canal and the spine. Usually it ll be possible 
Here there is straightening . Inter vertebral space normal , Bodies look normal except the fourth . Axis looks denser . Ring of atlas and atlanto axial relation normal 

Seeing this X Ray , she was re examined for bone and joint problems .It showed found out small swelling on forehead and painful areas on her scalp. There was pediculosis but no infected lesions to account for the pain 

Plane Xray skull lateral view 

Erosion of skull bones multiple sites ,without discrete margins sort of moth eaten appearance..Areas of sclerosis .

MRI brain and Spine 

Look at the Skull bones ..

Brain parenchyma , Pituitary Hypothalamic area was normal 

Cervical spine . the atlas and axis are involved. Lower level multiple vertebral bodies , thoracic and lumbar involved. 

No evidence of compression on spinal cord or medulla .
Reexamination CNS was done ,All deep tendon reflexes normal ,sensations normal

Two common entities at this age

1. Neuroblatoma 

2,Langerhan cell disorder . Eosinophilic granuloma
3 Chronic recurrent multifocal osteomyelitis 



Other Investigations 

Blood , Hb 6 grams, Total count 8000, N 60 ,L38,E2

Mantauxe negative 

Peripheral smear  showed  microcytic hypochromic RBCS 

WBC series and platelet count and distribution were normal 

 VMA 24 hour urine.....was  normal

USG abdomen . Liver , spleen normal ,No Mass Adrenals normal .

Xray chest .No  rib erosion, No mass in the chest. lung and heart shadow and mediastinum were normal 

Needle aspiration cytology Not done 

Bone marrow done  ...., No evidence of leukemia , lymphoma or neuroblastoma. 

Chronic Recurrent Multifocal Osteomyelitis is a rare entity 

( CRMO usually involves long bones than skull and spine even though it is possible . Here most of the long bones spared .Examination of clavicle did nt show any swelling or tenderness . Xray showed clavicles were normal .Clavicle is one of the commonest bone involved in CRMO)

We considered  Langerhans cell disorders as first possibility 

 .

She was referred to Regional Cancer center and she is on treatment from there