2696 Dysphagia: A Rare Presentation of Multiple Myeloma

Abstract

INTRODUCTION: Dysphagia is a common symptom with a broad differential diagnosis. Although the etiology of dysphagia is usually benign, it is critical to rule out serious causes. It is also important to think outside the box when the cause is not obvious. We describe a case of multiple myeloma that presented with dysphagia. CASE DESCRIPTION/METHODS: An 81-year-old male patient presented with progressive dysphagia to solid food associated with poor appetite and weight loss of 50 lb. over the last 6 months. Past medical history was significant for coronary artery disease, essential hypertension, hypothyroidism, chronic hepatitis B infection, and sarcoidosis. Past surgical history and family history were insignificant. Home medications included aspirin, atenolol, quinapril, levothyroxine, and entecavir. He denied the use of tobacco, alcohol, and illicit drugs. Review of systems was unremarkable On physical exam, the patient looked chronically ill and cachectic. Vital signs were within normal limits. Abdominal exam showed a soft, non-tender, and non-distended abdomen without organomegaly. Initial laboratory workup revealed microcytic anemia with a hemoglobin of 11.6 g/dL. He underwent upper endoscopy which revealed patchy erythema in the gastric antrum. Gastric biopsy was performed with findings of acellular, eosinophilic deposits and a Congo red stain showed apple-green birefringence on polarized light consistent with gastric amyloidosis. Further workup was done to look for the cause of amyloidosis. Serum and urine protein electrophoresis failed to show a monoclonal (M) band. Immunofixation revealed elevated free kappa light chains of 104.90 mg/dL and elevated free Kappa/Lambda ratio of 156.57. Bone marrow biopsy revealed that plasma cells constituted 28.5% of bone marrow cells. The patient was diagnosed with multiple myeloma (light chain myeloma) and was started on bortezomib, lenalidomide, and dexamethasone. During a follow-up visit 1 month later, he reported improvement in dysphagia and weight gain. DISCUSSION: Gastrointestinal involvement is common in patients who have amyloidosis. However, it is rare for amyloidosis to initially present with gastrointestinal symptoms. Depending on the site involved, patients can present with dysphagia, gastrointestinal bleeding, constipation, malabsorption, or protein-losing gastroenteropathy. Identification and treatment of the underlying disease, e.g. multiple myeloma, is important because it can lead to regression of gastrointestinal amyloidosis.