A RARE CASE OF PULMONARY PARENCHYMAL INVOLVEMENT OF MULTIPLE MYELOMA

Abstract

SESSION TITLE: Wednesday Medical Student/Resident Case Report Posters SESSION TYPE: Med Student/Res Case Rep Postr PRESENTED ON: 10/23/2019 09:45 AM - 10:45 AM INTRODUCTION: Multiple myeloma (MM) is a systemic disease primarily involving the bone marrow. In MM, the normal bone marrow is replaced by malignant plasmacytes, which produce monoclonal proteins and this disease process mainly involves the axial skeleton. MM constitutes about 1% of all malignancies and 10% of hematologic malignancies. Extra-medullary plasmacytomas form a small percentage of plasma cell tumors, and majority of which primarily occur in the head and neck. However, the occurrence of extramedullary disease is very uncommon in MM. Hereby, we present a case of unusual presentation of multiple myeloma involving lung parenchyma. CASE PRESENTATION: 64-year-old man diagnosed with metastatic disease of the lumbar spine, sacrum, and pelvis and was found to have multiple myeloma. He was treated with chemotherapy and ultimately underwent an autologous stem cell transplantation after 5 cycles of CY-BOR-D therapy. He was continued on Revlimid. His transplant was complicated by septic arthritis and recurrent osteomyelitis of the right fifth metatarsal bone and got treated. He started having shortness of breath with exertion, fatigue, dysarthria, increased drowsiness and his family felt that he was not acting right. These symptoms lasted for an hour. He was brought to the hospital. Initially there was concern of CVA but work up came out negative. Patient was noted to have a low-grade fever. His white count was low at 2900, hemoglobin 8.4. He had a CT angiogram performed, which was remarkable for multiple bilateral pulmonary nodules, which were new compared to his prior CTA and PET scan of last year. He was seen in consultation by his oncologist who raised the concern of possible malignancy; however, given the appearance and the unusual likelihood for myeloma to present in this fashion, opportunistic infection was also in consideration. His cryptococcal antigen, Aspergillus beta-D-glucan were negative. His blood cultures were negative. He had elevation in his free kappa light chains suggestive of multiple myeloma relapse. VATS procedure was done to obtain a biopsy to further characterize his lung nodules, results showed infiltrates of Plasma cell Myeloma. DISCUSSION: Pulmonary parenchyma is an uncommon site of extramedullary involvement in multiple myeloma. Looking at the presented case we recommend in appropriate scenarios clinical suspicion should be raised for multiple myeloma metastasis and biopsy in such patient is warranted. Presented case was diagnosed after we discovered the monoclonal plasma cells on VATS biopsy. CONCLUSIONS: Even after bone marrow transplant with immunosuppressive medications in lung parenchymal involvement suspicion of the metastatic process should be kept high and histopathological diagnosis should be considered since presentation can easily be confused with drug pneumotoxicity, infectious etiologies and other forms of DPLD and cause a delay in care. Reference #1: Vojnosanit Pregl. 2014 Jun;71(6):596-9. Myeloma multiplex with pulmonary dissemination. Terzić B, Maksić D Reference #2: Clin Respir J. 2017 Nov;11(6):1057-1059. Endobronchial plasmacytoma in patient with multiple myeloma. Sunnetcioglu A, Ekin S, Bayram I, Ekinci O, Bugday IB Reference #3: Br J Radiol. 2006 Jul;79(943):e25-7. Pulmonary and nodal multiple myeloma mimicking lymphoma. O'Sullivan P, Müller NL DISCLOSURES: No relevant relationships by Amnah Andrabi, source=Web Response No relevant relationships by Kashif Aslam, source=Web Response No relevant relationships by Thomas Fynan, source=Web Response No relevant relationships by Bindu Gandrapu, source=Web Response No relevant relationships by Preeyanka Sundar, source=Web Response