59-Year-Old Man With Pelvic Pain and Hypergammaglobulinemia

Abstract

59-year-old man was referred to our institution by his local physician for further evaluation and management of pelvic pain of 3 months’ duration. He had been well until 3 months previously when he developed left testicular pain with fever (temperature, 40°C) and vomiting. Two to 3 days later the fever had subsided, but he experienced severe pelvic pain, described as deep, poorly localized, and worse with weight bearing and hip abduction. Treatment with nonsteroidal anti-inflammatory agents and other analgesics provided little benefit. He denied having persistent fever, anorexia, or weight loss. There were no changes in bowel pattern and no hematochezia, hematuria, or worsening of the pain with micturition or bowel movements. Aside from the pelvic pain, findings on review of systems were normal. The patient’s medical history was unremarkable except for hyperlipidemia. Physical examination revealed only tenderness over the symphysis pubis. He had normal passive range of motion of his hips but had tenderness on abduction bilaterally. Slight edema of his left lower extremity was evident. An extensive evaluation before referral showed an elevated sedimentation rate (ESR) of 104/mm in 1 h (reference ranges shown parenthetically) (<10 mm/1 h), elevated IgG of 2680 mg/dL (700-1500 mg/dL), and normal IgM and IgA. Presence of a small monoclonal spike was suspected within a broad polyclonal band. A metastatic bone scan showed no lytic or sclerotic lesions. Magnetic resonance imaging (MRI) of his pelvis, performed to evaluate pelvic pain, showed only a slightly abnormal marrow signal. The possibility of multiple myeloma was raised, and he was referred for further work-up.