Presentation
General weakness. Pelvic x-ray done in another clinic, normal. Referred to US for investigation of a limping child. Fever.
Patient Data
No fluid in the hips, knees and ankles. No cortical nor metaphyseal anomaly.
2 year-old child. Upon asking the relatives in the US examination room, the child actually not only did not walk, but also refused to sit. The child was in discomfort whilst being moved from the US exam table to the wheelchair, and kept the neck inclined on the left at all times.
Spine MRI was warranted after US, with concerns of spondylodiscitis. The clinician referred the patient to bone scintigraphy.
Multiple foci of tracer uptake in the skeleton and right adrenal gland.
Concerns of neuroblastoma.
Enlarged, heterogenous adrenal gland with calcification.
Adrenal gland tumor with calcification. Most likely neuroblastoma in this age group.
Sclerotic vertebral metastasis.
Case Discussion
Limping child, really? If a child does not want to sit, radiologists and clinicians should think that there is no reason for this child to be uncomfortable upon sitting if there is a hip, knee, ankle or lower limb disorder. The radiologist should be aware of spine affections such as infectious spondylodiscitis, or as in this case, bone metastases (of a neuroblastoma). Spine MRI, or as in this case, bone scintigraphy, should be performed without delay.
Hutchinson syndrome is limping and irritability due to skeletal metastases and is a confusing yet classical presentation of a metastatic neuroblastoma.
Multiple bone metastases in a toddler should first raise suspicion of a neuroblastoma.
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