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Background
Multiple myeloma (MM) is a malignant proliferation of a single clone of plasma cells. Pleural effusion and skin manifestations in patients with MM are uncommon. Cutaneous and pleural involvements are usually associated with poor prognosis. We present a unique case of a patient with a clinical history of myeloma who developed subcutaneous nodules and pleural involvement without extension from an underlying bony focus of disease.
Case presentation
A 62-year-old woman, with no significant medical history, presented with a 6-month history of inflammatory back pain associated with intercostal neuralgia. There was no report of recent trauma or falls. Physical examination revealed tenderness over the area of the spinal process of T8. Neurological examination was unremarkable.
Investigations
Laboratory investigations showed an elevated erythrocyte sedimentation rate (62 mm/h). The complete blood cell count revealed anaemia (haemoglobin level of 9 g/dL). Serum level of calcium was within the normal range. Renal and liver function tests were unremarkable. Thoracic spine X-ray showed vertebral body collapse of T8. MRI of the spine revealed collapse of the vertebral body of T8 associated with compression of the spinal cord. X-ray of the skull, humeri, ribs, pelvis and femora did not show lytic bone lesions. Serum protein electrophoresis revealed a marked increase in [beta]-globulin classified by immunoelectrophoresis as IgA [kappa] monoclonal gammopathy. Quantitative immunoglobulin tests revealed high serum IgA levels (675.8 mg/dL) with reduced IgG and IgM. Urine electrophoresis showed no Bence-Jones proteins. A bone marrow aspirate showed infiltration of malignant plasma cells of 15%. The diagnosis of symptomatic IgA [kappa] MM was therefore confirmed. According to Durie-Salmon staging, the disease was classified as stage IIIA.
Treatment
The patient was eligible for autologous stem cell transplantation. An induction regimen was introduced including thalidomide and dexamethasone in addition to zoledronic acid. The patient also underwent radiation therapy to the T8 vertebrae (daily doses of 30 Gy delivered over 10 sessions), complicated by radiation oesophagitis.
Outcome and follow-up
After the third cycle of the induction regimen, haematological findings revealed disappearance of [beta]-globulin spike, and bone marrow aspirate showed a decrease in the plasma cell infiltration, at 4%. Given the risk of gastrointestinal perforation related to radiation oesophagitis, autologous transplantation was deferred and the patient was considered in remission.
Three months later, she re-presented with slightly...