Multiple myeloma presenting with spinal cord compression during pregnancy

Abstract

Dear Editor, Multiple myeloma (MM) is diagnosed before the age of 40 in just 2% of cases [1]. Accordingly, reports of MM in pregnancy are rare, with eight cases arising during pregnancy reported in the literature to date. Here we report the case of a young woman who presented with an aggressive form of MM during the third trimester of pregnancy with spinal cord compression. This is the first report of spinal cord compression secondary to MM presenting during pregnancy. A 39-year-old woman presented with a 3 week history of back pain and a 24 h history of urinary retention and bilateral lower limb weakness at 32 weeks gestation. Emergency MRI spine showed replacement of the T12 vertebral body by abnormal soft tissue with epidural extension, compressing the spinal cord (Fig. 1). She underwent emergency caesarean section delivering a healthy son followed by emergency spinal decompression surgery where a tumour was removed from the T12 vertebral body. She was commenced on dexamethasone and began to make an excellent neurological recovery. Biopsy demonstrated a plasmacytoma, an unusual feature of which was the high proliferation index of 70% Six days later she again developed lower limb weakness and sphincter disturbance. Urgent MRI spine revealed there had been a substantial increase in the volume of an epidural mass lying posterior to the cord from T10 to L1. Note was also made of foci of abnormal signal in many of the other vertebral bodies. She underwent further decompression of the spinal cord followed by radiotherapy to the thoracolumbar spine, (20 Gy) in five fractions. Further investigations confirmed a diagnosis of MM: skeletal survey demonstrated lytic lesions in the pelvis, femora and skull. Serum protein electrophoresis revealed an IgG lambda paraprotein (11 g/l) and Bence Jones proteinuria was also detected of 0.09 g/l. Trephine biopsy demonstrated 5% lambda light-chain restricted plasma cells. Albumin was 35 g/l, beta-2-microglobulin 1.7, and renal function, calcium and full blood count were all normal prior to surgery. She commenced chemotherapy with two cycles of idarubicin and dexamethasone with minimal response and then received second line chemotherapy, ESHAP (etoposide, cisplatin, cytarabine, methylprednisolone). Repeat MRI after the second cycle showed a partial response. Allogeneic bone marrow-transplantation was not considered at this time in view of her poor performance status and lack of a HLA-matched sibling, so she proceeded to highdose therapy with peripheral blood stem cell rescue. Three Ann Hematol (2009) 88:181–182 DOI 10.1007/s00277-008-0558-9