A 60-year-old male was referred to our clinic with 5-month history of gradual but progressive weight loss, recurrent fever, anorexia, progressive fatigue, and generalized bone pains. Two months after the onset of these symptoms, he developed inability to walk. There was no associated sphincteric dysfunction or sensory loss. There was no history of chronic cough. At the time of presentation, significant examination findings were pallor, inability to walk, and general bone tenderness. X rays of the skull, thoracolumbar spine, and pelvis showed lytic lesions (). Blood film and bone marrow aspiration were essentially normal with <5% plasma cells reported in the bone marrow. Erythrocyte sedimentation rate, C reactive protein, and serum protein electrophoresis were normal and urinary Bence Jones protein was negative. Laboratory data are summarized in .\nA bone marrow trephine biopsy was done and showed osteosclerotic changes and focal scalloping with prominent osteoclastic activity. The marrow was moderately to markedly hypercellular and was densely infiltrated by a cellular infiltrate. The cells were mostly small cells with fairly condensed chromatin. They showed a variable amount of cytoplasm and there was a fair sized subpopulation of plasmacytoid lymphocytes.\nImmunohistochemistry showed positivity of CD138 (which strongly supports the diagnosis of plasma cell myeloma) and cyclin D1 (which is associated with cases of plasma cell myeloma with lymphoplasmacytic morphology and correlates with the presence of the translocation t(11;14)(q13;q32)).
A 60-year-old man presented with a history of lower back pain that had persisted for 2 years and difficulty walking for 2 months. The patient received a complete hemogram as well as routine biochemical and radiographic imaging studies. His hemoglobin level was 15.3 g/dL, his total leukocyte count was 6.1×109/L, his platelet count was 160×109/L, and his erythrocyte sedimentation rate (ESR) was 15 mm. No rouleaux formation was seen on a peripheral smear. Serum blood urea nitrogen (27 mg/dL), creatinine (1.06 mg/dL), calcium (9.9 mg/dL), and albumin (5.1 g/dL) were all within normal limits. Serum uric acid levels were high (7.6 mg/dL), Alkaline phosphatase levels were slightly increased (134 U/L), and the patient had subnormal vitamin D3 levels. Ultrasonography findings were within normal limits, except for mild prostatomegaly. Serum prostate specific antigen and carcinoembryogenic antigen levels were within normal limits.\nA radiograph of the dorsolumbar spine showed diffuse osteoporosis and wedging of the D12 vertebra. Multiple small permeative lesions were seen in the pelvic bones and proximal femoral shafts. MRI findings showed diffuse degenerative changes in the cervical and lumbar spine and D12 vertebral collapse. Bone scan showed increased uptake in the anterior region of the 6th rib, left sacroiliac joint, and occipital region. Serum protein electrophoresis did not show any M spike, and gamma globulin levels were normal (8.8 g/L). Urine protein electrophoresis showed protein levels of less than 60 mg/L and no M spike. The bone scan findings, together with increased serum uric acid and alkaline phosphatase levels, and negative myeloma workup suggested possible diffuse skeletal metastasis. The patient underwent bone marrow aspiration from the bilateral posterior iliac spines and unilateral trephine biopsy to look for any secondary causes of bone scan findings and to rule out the presence of a plasma cell neoplasm. The aspirates from both sides showed similar findings, with numerous plasma cells ranging from 60–70% (). Binucleated or multinucleated forms, plasmablasts, and occasional mitotic figures were also observed in those plasma cells. Additionally, intranuclear Dutcher bodies and occasional Mott cells were observed. The Congo red stain for amyloid on the trephine biopsy was negative. IHC was performed on the trephine biopsy, revealing cells positive for CD138, MUM 1, and cytoplasmic κ and negative for CD3, CD20, LCA, CD56, and lambda (λ). The Ki-67 labelling index was 15%. The mean λ FLC level was 11.2 mg/L (range, 5.5–26.3 mg/L), and that of κ was 176.8 mg/L (range, 3.3–19.4 mg/L). The mean κ/λ ratio was 15.78 (range, 0.2–1.65). Patient had high β2-microglobin levels, at 2,557 mg/mL (range, 609–2,366 mg/mL).\nThe patient was in clinical stage I according to the International Staging System (ISS) for plasma cell myeloma and stage IIIA according to the Durie-Salmon staging system. The patient was referred to the oncology center for further management. There the patient was treated with a chemotherapy regimen that included the proteasome inhibitor bortezomib and dexamethasone.