A 55-year-old male presented with 10 months of intermittent fever and 7-8 months of neck pain. Examination found a 4cm firm mass on his right 4th rib. Tests showed anemia, elevated ESR, monoclonal band, and over 20% plasma cells in bone marrow. CT and MRI found lytic lesions in vertebrae, ribs, and soft tissue mass. Biopsy of rib mass was positive for malignancy. He met diagnostic criteria for multiple myeloma with M-protein, bone lesions, and over 30% plasma cells. He was started on chemotherapy including bortezomib, cyclophosphamide, and dexamethasone as primary induction therapy as a transplant candidate.
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1. A CASE OF FEVER WITH
BONY PAINS
HISTORY
• 55 year old male presents with:
• CHIEF COMPLAINS:
• On and off fever × 10 months
• Pain in the nape of the neck × 7-8 months
-Arpita Khasnavis
MBBS 2011
2. HISTORY OF PRESENTING ILLNESS
FEVER
Duration :10 months, on and off type, associated with
night sweats, no diurnal variation, not associated with
rigors and chills.
relieved by antipyretics to reoccur a few days later.
Was associated with weight loss.
PAIN
H/O pain in the nape of neck for the last 7-8 months,
started abruptly, having moderate intensity.
Dull and persistent pain, aggravated by movement
around the neck with minimum relief with medication,
no radiation.
3. EXAMINATION
Body weight: 51 kg, Height: 1.75 m
BMI: 16.6kg/m2
Oriented to time, place and person.
B.P: 116/ 72 mm Hg, H.R.:88/min.
P⁺/I⁻/Cy⁻/Cl⁻/LAP⁻/PE⁻/JVP(N)
Respiratory system:
◦ B/L vesicular breathing, no adventitious sounds
heard.
◦ mass was palpable near the 4th rib on right side.
Rest of the systemic examination was unremarkable.
4. Description of the mass near
4th rib
1. Location 4th rib, mid clavicular line
2. Shape and size Circular, diameter approx. 4cm
3. Visible on
inspection
No, only palpable
4. Tenderness Present
5. Edges Irregular
6. Consistency Firm
7. Mobility Absent
8. Adherence Present to underlying bone
5. Lab Investigations
Hemoglobin 7.8 g/dl
Total
leucocyte
count
6000/cmm
Differential
leucocyte
count
78/18/2/2
Absolute
platelet
count
1 lac/cmm
ESR 122mm/hr
Possibility of a
lesion on 4th
rib.
X-RAY CHEST: A-P VIEW TO CHECK FOR ANY LESION
IN THE RIBS
6. C.T. SCAN SHOWING
SOFT TISSUE
WINDOW
Lytic areas with enhancing soft tissues on multiple vertebrae, ribs.
AXIAL SCAN:
Large soft tissue component of
intermediate density extending on
right side. Involvement of posterior
aspect is better appreciated.
SAGITTAL SCAN:
Altered marrow signal density in T1
extending in right sided posterior element
which shows intermediate signal density
on T1 and T2
M.R.I
7. FINE NEEDLE ASPIRATION CYTOLOGY OF
PALPABLE MASS :
Positive for malignancy.
Possibility ranking high in the order being multiple
myeloma.
BONE MARROW ASPIRATION:
Marrow shows prominent plasma cells >20%.
Other normal hematopoietic elements are
reduced.
Plasmacytoma to be co-related with
radiological findings and serum
electrophoresis.
8. Biochemical Examination
TEST NAME RESULT NORMAL VALUE
Serum protein 13.3 g/dl 6.00-8.00 g/dl
A/G ratio 0.6 2:1
Gamma globulin 6.92 g/dl 0.60-1.60 g/dl
Myeloma bands M bands
Urine examination:
• Bence jones
proteins
Present Absent
Serum protein electrophoresis
shows a prominent M band at
the junction of Beta 2 and
Gamma region in the
background of
hypergammaglobulinemia
9. Differential Diagnosis
Multiple Myeloma Waldenstrom
Macroglubulinemia
Hepatospleenomegaly __ +
Lymphadenopathy __ +
Hyperviscosity __ +
Bence jones proteins
in urine
More commonly seen Less commonly seen
Coomb’s test +ve Less commonly seen More commonly seen
Bony Lesions More common Less Common
10. Diagnostic Criteria for
MULTIPLE MYELOMA
MAJOR CRITERIA
I = Plasmacytoma on tissue biopsy.
II = Bone marrow with greater than
30% plasma cells.
III = IgG peak of greater than 3.5
g/dL or an IgA peak of greater than
2 g/dL, or urine protein
electrophoresis (in the presence of
amyloidosis) result of greater than
1 g/24 h
MINOR CRITERIA
a = Bone marrow with 10-30%
plasma cells.
b = Monoclonal globulin spike present
but less than category III
c = Lytic bone lesions
d = Residual IgM level less than 50
mg/dL, IgA level less than 100 mg/dL,
or IgG level less than 600 mg/dL
The following combinations of findings are used to make the diagnosis of
multiple myeloma:
I plus b, c, or d
II plus b, c, or d
III plus a, c, or d
a plus b plus c
a plus b plus d
11. MANAGEMENT
Chemotherapy.
High dose chemotherapy or Bone marrow or stem
cell transplantation may be done.
The 2011 NCCN MM guidelines added the
following therapies :
Combination of:
1 Bortezomib/ cyclophosphamide/dexamethasone
(primary induction therapy for transplant
patients)
2 Bortezomib/dexamethasone (primary induction
therapy for those who are not candidates for
transplantation)
3 Melphalan/prednisone/lenalidomide (primary
induction therapy for non transplant patients)
Editor's Notes
Patient had a history of Alcoholism. Has stopped drinking since the last 10 months.
Negative History: no history of cough, hemoptysis, hematemesis, loose stools, blurring of vision, dizziness, altered sensorium, burning urination, no decrease in urine output.
KFT REPORT:
BLOOD UREA: 71mg/dl (normal- 10 to 50 mg/dl
Serum creatinine: 2.4mg/dl(normal=0.7 to 1.3 mg/dl)
Serum Uric acid:8.4mg/dl(3-7 mg/dl)
WHAT IS MULTIPLE MYELOMA??
Cancer of plasma cells.
Healthy plasma cells produce antibodies or immunoglobulins.
Part of our humoral immunity, they are released in response to foreign body invasion.
Myeloma cells produce abnormal immunoglobulin.
Overproduce monoclonal protein or paraprotein.
Ineffective immunoglobulins.
Leads to decreased bone marrow function.
Destruction of bone tissue.
