An Unusual Presentation of Multiple Myeloma

Published: April 1, 2024 | DOI: https://doi.org/10.7860/JCDR/2024/68544.19305

Ashwin Karnan, Babaji Ghewade

1. Junior Resident, Department of Respiratory Medicine, Datta Meghe Institute of Higher Education and Research, Wardha, Maharashtra, India. 2. Professor and Head, Department of Respiratory Medicine, Datta Meghe Institute of Higher Education and Research, Wardha, Maharashtra, India.

Correspondence
Dr. Ashwin Karnan,
Junior Resident, Department of Respiratory Medicine, Datta Meghe Institute of Higher Education and Research, Wardha-442004, Maharashtra, India.
E-mail: ashwin2700@gmail.com

A 62-year-old female presented to the Outpatient Department (OPD) of respiratory medicine with complaints of breathing difficulty, dry cough, and chest pain for the past two days. The patient was normal two days ago, following which she developed a dry cough that was insidious in onset and progressive in nature, associated with breathlessness on exertion and progressed to breathlessness at rest. The chest pain was diffuse, dull aching, and non radiating. She had no similar illness in the past, no significant family history, and no history of any deleterious habits.

On examination, the patient was conscious and oriented, with a height of 152 cm, weight of 40 kg, Body Mass Index (BMI) of 17.78 (underweight), a pulse rate of 120 beats per minute, a respiratory rate of 34 breaths per minute, a blood pressure of 110/70 mm Hg, an oxygen saturation of 75% on room air, 96% with Non Invasive Ventilation (NIV) support with FiO₂ 100% and Positive End Expiratory Pressure (PEEP) 5 cmH₂O. Bilateral crepitations were heard in all areas on auscultation. Tenderness was present over the lumbar region, and other systemic examinations were normal.

The 12-lead Electrocardiogram (ECG) was within normal limits. Arterial blood gas analysis suggested Type I respiratory failure. The chest X-ray showed bilateral bronchopneumonia (Table/Fig 1). The High-Resolution Computed Tomography (HRCT) of the thorax showed bilateral patchy consolidation with cardiomegaly (Table/Fig 2).

Blood investigations revealed normocytic normochromic anaemia (haemoglobin 8.5 g/dL), an elevated serum calcium level (serum calcium 14 g/dL), hyperglobulinaemia (globulin 8.0 g/dL), renal failure (urea 90 mg/dL, creatinine 2.5 mg/dL). All these findings were indicative of Multiple Myeloma (MM) as the diagnostic CRAB criteria (Calcium elevation, Renal insufficiency, Anaemia, and Bone abnormalities) were fulfilled (1). Based on this, an X-ray of the skull was also performed, which showed punched out osteolytic lesions (Table/Fig 3). A lateral X-ray of the lumbar spine revealed a compression fracture of the L5 vertebra (Table/Fig 4). Serum protein electrophoresis showed a spike in the gamma M band (gamma M spike 5.74 H), and the serum free light chain assay showed elevated levels of free lambda light chain (4.40 g/dL) (Table/Fig 5).

Based on all the findings, a diagnosis of MM with bronchopneumonia was made. The patient was treated with intravenous antibiotics, intravenous fluids, loop diuretics, and other supportive measures. A medical oncologist’s opinion was sought in view of MM, and the patient was transferred to their department for a bone marrow biopsy, cytogenetic study, followed by chemotherapy.

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