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 male was referred to our clinic with complaints of low back ache of one year duration. The pain was radiating down the right lower limb as far as the knee joint. There was no history of trauma or history suggestive of any significant medical co-morbid conditions.\nExamination revealed tenderness on the right side of the lumbosacral spine and right sacroiliac joint. There was para vertebral muscle spasm with loss of lumbar lordosis. Hip movements were normal with no major disability. There were no root stretch signs and no neurological deficit was noted.\nAn x-ray of the lumbosacral spine showed evidence of old fracture of L1 vertebra []. The Magnetic Resonance Imaging (MRI) scan showed collapse of the L2 vertebra with extrusion of the bone posteriorly into the spinal canal []. There was soft tissue infiltration seen in the sacrum. While awaiting clinic review the patient presented to the casualty with fracture clavicle on the left side following a trivial fall. The fracture of the clavicle was at the medial end (unusual site). A subsequent bone scan showed increased uptake in the medial end of the left clavicle and L2 vertebra. There were areas of increased activity in the region of the ribs [].\nLab investigations revealed hemoglobin of 12.8 g/dl, erythrocyte sedimentation rate (ESR) of 21mm/hr and hematocrit ratio of 0.357 (normal 0.370-0.470 ratio). Creatinine was 50 μmol/l (normal 50-141μmol/l) and urea of 5.9mmol/l (normal 2.5-7.5 mmol/l). The serum calcium 2.28 mmol/l (normal 2.1-2.6 mmol/l) and phosphate levels 1.13 mmol/l (normal 0.81-1.45 mmol/l) were normal. Lactic acid dehydrogenase was elevated, 1061 IU/l (normal 313-618 IU/l) and Alkaline phosphatase was normal, 125 IU/l (normal 25-150 IU/l).\nMyeloma screen which did not reveal presence of any abnormal compact bands was obtained and there was no Bence-Jones proteinuria. The levels of the immunoglobulin were Ig G 6.6 g/l (normal 5.3-16.5 g/l), Ig A 0.21 g/l (normal 0.80-4.00 g/l) and Ig M was 0.36 g/l (normal 0.50-2.00 g/l), which were lower than normal.\nIn view of the bony pain, pathological fracture of the L2 vertebra, unusual fracture of the clavicle, normal myeloma screen, normal calcium levels and bone scan findings it was decided to organize a Computerized Tomography (CT) scan of the thorax and abdomen to look for the primary with secondaries as the first working diagnosis. The CT scan merely confirmed the findings of MRI scan and there was no evidence of any primary or other secondaries []. A bone biopsy was planned.\nA percutaneous bone biopsy from the medial end of the clavicle was done because of easy accessibility which was negative for malignancy. A CT guided biopsy from the L2 vertebra was again negative for malignancy. A bone marrow aspirate and trephine biopsy were done from the iliac crest which confirmed the diagnosis of multiple myeloma. The biopsy showed a hyper cellular marrow with normal haemopoiesis replaced entirely with malignant plasma cells suggestive of myeloma. Aspirate showed plasma cells to be about 52% of the marrow with marked atypia. The patient was referred to further treatment in the form of chemotherapy and radiotherapy. The patient died one month after diagnosis while undergoing treatment. There was, however, a delay of two months between the first presentation and final diagnosis.