A 65-year-old man presented with a 2-year history of progressive hair loss involving the scalp, the eyebrows and the upper trunk, and recent onset of small papules and blisters on the dorsal hands as well as longitudinal ridging and fissuring of the fingernails. Clinical examination showed diffuse alopecia most pronounced on the androgen dependent scalp; the skin was slightly indurated on palpation []. There were focal petechiae. The lateral sides of both eyebrows and most of the hair on the chest were absent too. The axillary, pubic, and limb hair was preserved.\nTrichoscopic examination of the scalp showed prominent salmon colored halos (0.3-1 mm in diameter) surrounding the follicular ostia []. These halos were seen around empty follicles as well as around follicles containing terminal and vellus hairs, black dots, and/or broken hairs. This trichoscopic finding was present over the entire scalp.\nA 4 mm punch biopsy from the alopecic scalp was obtained and bisected in horizontal sections. There was overall preserved follicular architecture with intact sebaceous glands []. There were no terminal anagen follicles, one terminal telogen follicles, two vellus anagen follicles and 10 atrophic follicular structures reminiscent of telogen germinal units (secondary germs). All follicular structures were surrounded by amorphous eosinophilic material, which formed either a compact- or loosely- folded fibrillar cast []. The same material was deposited in all fibrous streamers, which appeared eosinophilic, homogenized and avascular. Congo red stain evaluated under polarized light highlighted the apple green stain of the amyloid [].\nSerum electrophoresis and bone marrow biopsy established the diagnosis of multiple myeloma.
The present case is of a 60 year old woman who initially presented with back pain. There was no history of trauma or history suggestive of any comorbid conditions.\nExamination revealed tenderness on right side of lumbosacral spine and right sacroilliac joint. Hip movements were normal.\nMRI scan showed wedge compression fracture of D6, D7, D9 & D10 vertebrae with areas of altered signal intensity involving right sided pedicle of D9 & D10 vertebrae compressing the thecal sac and dorsal spinal cord.\nEdema in dorsal spinal cord at D10 level was also noted.\nLab investigations revealed\nHemoglobin of 13g/dl,\nTotal Leukocyte Count of 10,890 and\nPlatelet count of 1.5 lac/cumm.\nESR =27mm/hr\nViral markers revealed HCV positive (incidental finding).\nHypercalcemia with a serum calcium level of 12.5g/dl.\nPBF shows normal blood picture with mild neutrophilia (75%) and no rouleaux formation.\nBone marrow aspiration and biopsy revealed plasmacytosis (>45%)\nSerum protein electrophoresis showed absence of M band with hypogammaglobulinemia.\nThe above patient meets the criteria laid down by the international myeloma working group and chronic leukemia myeloma task force.\nIt was also a diagnostic dilemma as other disorders such as secondary deposits, osteoporosis and hyperparathyroidism can present with a similar picture.\nOur patient did not undergo serum immunoglobulinfree light chain assay (FLC).\nNow patient is currently being managed on the lines of treatment of multiple myeloma.