A RARE PRESENTATION OF PLEURAL PLASMACYTOMA

Abstract

TOPIC: Disorders of the Pleura TYPE: Medical Student/Resident Case Reports INTRODUCTION: Plasmacytoma is an extremely rare neoplastic proliferation of plasma cells. Among multiple subtypes, the main three subtypes of plasmacytoma are multiple myeloma, solitary plasmacytoma, and extramedullary plasmacytoma (EMP). EMPs present in <5% of plasma cell neoplasms. The most common sites of origin are the head and neck region. Still, in nearly 4% of cases, it involves the nasal cavity; in few cases, it involved the parotid gland, intraocular soft tissues, and others. It can affect any part of the body, but their involvement in the pleura is infrequent. EMP can progress to multiple myeloma throughout the disease. CASE PRESENTATION: An 84-year-old gentleman with a past medical history of dyslipidemia, hypertension, congestive heart failure presented to the ED two years ago with a complaint of bilateral lower extremity edema, orthopnea, and shortness of breath on exertion. He had these symptoms for few weeks, progressively getting worse. On workup, laboratory data showed normal calcium (10.1 mg/dL), average blood urea nitrogen and creatinine (18 mg/dL and 0.75 mg/dL, respectively), and no evidence anemia. Computed Tomography of the chest showed large pleural effusion on the chest's left side. He was medically managed, underwent thoracentesis with pleural fluid analysis. The pleural fluid cytology was positive for atypical plasmacytoid cells. He continued to have worsening shortness of breath hence underwent chest tube placement. Bone marrow aspiration biopsy revealed 2% plasma cells and less than 5% CD 138+ve cell population with normal Flow cytometry. Immunoglobin levels (IgG, IgA, IgM) and Kappa lambda ratio were normal. PET CT scan showed granuloma in the left lower lobe and mild pleural thickening. Our patient had multiple medical co-morbidities and stable shortness of breath after thoracentesis; he decided to observe the malignancy with a regular follow-up visit with oncology. On the follow-up visits, he is monitored for progression to multiple myeloma. DISCUSSION: EMP most commonly affects males in their fifth and seventh decade of life, but the young population was also affected in few cases. The diagnostic criteria of EMP are the following: No bone marrow involvement, Pathological tissue evidence of monoclonal plasma cells involving a single extramedullary site, Negative skeletal survey results, No anemia, hypercalcemia, or renal impairment caused by plasma cell dyscrasia, Low serum or urinary levels of monoclonal immunoglobulin, Nearly two-thirds of the patient with EMP have survival >10 years. CONCLUSIONS: EMP involving the pleura is rare. As patients with EMP tends to get converted to multiple myeloma, all of them need close follow-up for surveillance. REFERENCE #1: Rothfield RE, Johnson JT, Stavrides A. Extramedullary plasmacytoma of the parotid. Head Neck. 1990 Jul-Aug;12(4):352-4. doi: 10.1002/hed.2880120414. PMID: 2193906. DISCLOSURES: No relevant relationships by Rahul Gosain, source=Web Response No relevant relationships by David Lucero, source=Web Response No relevant relationships by Shobha Mandal, source=Web Response No relevant relationships by Shista Priyadarshini, source=Web Response no disclosure on file for Oneeb Sanuallah; No relevant relationships by Layla Sulaiman, source=Web Response