Can Chronic Myeloid Leukemia (CML) cause bilateral hip pain?

Bilateral Hip Pain in Chronic Myeloid Leukemia

Chronic Myeloid Leukemia (CML) rarely causes bilateral hip pain directly, but it can be associated with complications that may manifest as hip pain, such as pyomyositis, bone marrow expansion, or treatment-related effects.

CML and Musculoskeletal Manifestations

CML is a myeloproliferative neoplasm characterized by the Philadelphia chromosome or BCR-ABL1 rearrangement 1. The disease typically presents with:

• Leukocytosis with left-shifted granulocytosis
• Splenomegaly (present in >50% of cases)
• Basophilia
• Thrombocytosis

While musculoskeletal pain is not a primary feature of CML, there are several mechanisms by which CML could be associated with bilateral hip pain:

Potential Causes of Hip Pain in CML

1. Bone Marrow Expansion

   • Excessive proliferation of leukemic cells can cause bone marrow expansion
   • May lead to bone pain, though this typically affects the long bones and spine rather than specifically the hips

2. Infections

   • CML patients may be immunocompromised
   • Pyomyositis (infection of skeletal muscle) can occur and present as hip pain
   • There is a documented case of bilateral adductor pyomyositis presenting as hip pain in a 17-year-old with CML 2

3. Treatment-Related Effects

   • TKI therapy (standard treatment for CML) can cause musculoskeletal pain
   • Imatinib commonly causes muscle cramps (49.2% of patients) and musculoskeletal pain (47%) 3
   • Joint pain occurs in 31.4% of patients on imatinib 3

4. Leukemic Infiltration

   • Rare but possible in advanced disease

Diagnostic Approach for Hip Pain in CML Patients

When a CML patient presents with bilateral hip pain, consider:

1. Assess CML Status

   • Determine disease phase (chronic, accelerated, or blast)
   • Review recent blood counts and BCR-ABL1 levels
   • Evaluate response to current therapy

2. Imaging Studies

   • MRI of hips to evaluate for:
     • Bone marrow changes
     • Avascular necrosis (potential complication of treatment)
     • Infection (pyomyositis, osteomyelitis)
   • X-rays to assess bone integrity

3. Laboratory Evaluation

   • Inflammatory markers (ESR, CRP)
   • Blood cultures if infection suspected
   • Consider joint aspiration if effusion present

Management Considerations

Treatment depends on the identified cause:

1. If Infection-Related

   • Prompt antibiotic therapy (consider coverage for Staphylococcus aureus)
   • Surgical drainage may be necessary for abscesses
   • The case report showed improvement within 72 hours of antibiotic treatment 2

2. If Treatment-Related

   • Evaluate need for TKI dose adjustment
   • Consider switching to a different TKI with fewer musculoskeletal side effects
   • Pain management with NSAIDs or other analgesics

3. If Due to Disease Progression

   • Optimize CML therapy according to guidelines 1
   • Consider bone-targeted therapies if bone involvement

Conclusion

While bilateral hip pain is not a common direct manifestation of CML, it can occur due to complications or treatment effects. The case report of bilateral adductor pyomyositis 2 demonstrates that hip pain can be an unusual presentation of CML-related complications. A thorough evaluation is necessary to determine the specific cause and appropriate management strategy.

For CML patients with persistent hip pain, consider infectious complications, treatment-related effects, and disease-related bone marrow changes as potential causes requiring specific interventions.