A 70-year-old man with a past medical history of dyslipidemia was referred to Jeju National University Hospital with a 5-month history of recurrent vertebral compression fractures with back pain. He suddenly had back pain while changing his pants and was treated for T11 and L3 vertebral compression fractures 5 months prior. He had slipped down on the stairs, landing on his backside, and was hospitalized for treatment of L2 and L4 vertebral compression fractures 2 months prior. He had felt back pain while sneezing and had difficulty in walking 5 days prior. Eventually, he was referred to our hospital. Bone densitometry of the spine from previous hospital visits revealed osteopenia, and magnetic resonance imaging (MRI) of the lumbar spine from a previous hospital visit showed multiple compression fractures of the vertebral bodies with inconspicuous retropulsion of the cortex into the spinal canal (). X-ray images of the T-L spine () revealed degenerative changes with compression fractures at T12, and the L1 to L3 vertebral bodies and the pelvic bones () showed osteopenia. A bone scan () showed a vertebral compression fracture in the L1 spine area; post-traumatic changes in the right first and eighth to tenth ribs and the left sixth rib; and arthritic and degenerative changes in the T9 to L5 spines and both hip joint areas.\nLaboratory tests did not reveal specific results. The hemoglobin level was 11.0 g/dL, showing normocytic normochromic anemia on the peripheral blood smear. We also noted the absence of hypercalcemia (8.9 mg/dL), and a normal serum creatinine level of 0.78 mg/dL. Laboratory tests and imaging studies did not provide evidence to suspect that the recurrent compression fractures may have resulted from osteoporosis, metabolic diseases such as hyperparathyroidism, Paget disease and other metabolic processes, or obvious tumors. Therefore, serum and urine protein electrophoresis were conducted for the differential diagnosis of MM. Serum protein electrophoresis did not reveal abnormal Ig levels and the patient’s gamma globulin levels were normal. Urine protein electrophoresis showed no monoclonal protein in any significant fraction. Consequently, a presumptive diagnosis of vertebral compression fractures with osteopenia was made, and conservative management was undertaken for 2 weeks.\nHowever, the patient complained of right hip pain during his first ambulation after conservative management. Hip X-ray images () suggested several osteolytic lesions, and computed tomography detected multiple inconspicuous osteolytic lesions with greater variegation in opacity than expected in the spine, pelvic bones, both femurs, and ribs, suggesting MM or metastasis (). In addition, positron emission tomography revealed a high possibility of bone metastasis or bone-related malignancy based on a significant abnormal 18F-fluorodeoxyglucose uptake in the skull, spine, sternum, ribs, scapula, pelvic bones, and both femurs (). Moreover, a serum free light chain (SFLC) assay revealed elevated levels of kappa free light chain (12.667 mg/dL) and abnormal free light chain ratios with free lambda (1.105 mg/dL).\nTherefore, we performed a bone marrow biopsy for the definitive diagnosis of NSMM. The marrow was mildly to moderately hypercellular and infiltrated by plasmacytoid cells in clusters with some normal hematopoietic cells (). The plasmacytoid cells showed reactivity to CD138 () and kappa free light chain on immunohistochemical staining (), with no reactivity to lambda light chain (), which supports monoclonal plasma cell proliferation and favors the diagnosis of MM. Finally, the patient was diagnosed with NSMM 7 months since the onset of the first symptom and was referred to the oncology center for further management and therapy.
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.