Co-incidental presentation of IgA lambda multiple myeloma and pleural involvement with IgM kappa non-Hodgkin's lymphoma

Coexisting multiple myeloma, lymphoma, and non-small cell lung cancer: a case report and review of the literature

Multiple myeloma is a plasma cell dyscrasia characterized by neoplastic proliferation of plasma cells, producing a monoclonal immunoglobulin. Small lymphocytic lymphoma (SLL) is a neoplasm consisting of monoclonal B-cell lymphocyte proliferation. We present an extremely rare case of coexisting multiple myeloma, SLL, and squamous cell carcinoma of the lung in a 74-year-old female patient. She initially presented with a midline mass with pain in the lumbar area. Debulking surgery was performed, and pathology showed plasmacytoma. Further evaluation revealed coexistent IgG kappa myeloma. Imaging revealed extensive abdominal lymphadenopathy, and mesenteric lymph node biopsy confirmed the presence of SLL. The patient was also found to have a mass in the left lower lobe of the lung; biopsy showed squamous cell carcinoma. This patient was treated with lenalidomide and dexamethasone for multiple myeloma, and stereotactic body radiotherapy for limited stage lung cancer. Due to the more indolent course of SLL, watchful waiting was applied.

Ascites as the presenting symptom of multiple myeloma in a scleroderma patient

Several reports have demonstrated associations between scleroderma and cancer and between multiple myeloma and autoimmune diseases. Few papers have also reported the concurrence of scleroderma and multiple myeloma. We report a case of multiple myeloma that developed in a male patient after 28 years of fulfilling a diagnosis of scleroderma. The main presenting feature of multiple myeloma was ascites, solely explained by the increased vascular permeability that occurs in this disease.

Bilateral Pleural Effusions due to Pulmonary Amyloidosis as the Presenting Manifestation of Multiple Myeloma

Multiple Myeloma is a hematologic malignancy of plasma cell origin. Pleural effusion may develop in the setting of myeloma due to various reasons but is extremely uncommon as a presenting symptom. A 69-year-old Caucasian man presented with pleural effusions of undetermined etiology after extensive work up, and multiple failed pleurodesis. Lung biopsy revealed pulmonary amyloidosis and led to the diagnosis of multiple myeloma. Patient was started on chemotherapy but died within 6 weeks of his diagnosis due to multiorgan failure. Pulmonary amyloidosis should be suspected as a cause of intractable pleural effusions, even in patient who do not have evidence of lung involvement on imaging studies or typical features of multiple myeloma. Pleural effusions due to amyloidosis are often refractory to treatment, and a high index of suspicion is required for early diagnosis and treatment.

Unilateral massive pleural effusion: a presentation of unsuspected multiple myeloma

Pleural effusion in case of multiple myeloma is usually multifactorial but effusion due to myelomatous deposition of pleura is extremely uncommon. We are reporting a unique case of unsuspected multiple myeloma presenting as left sided massive pleural effusion due to myelomatous deposit in pleura and a rare M-band in the alpha-2 region in serum protein electrophoresis. A 61 year lady presented with cough, weakness and progressive shortness of breath. Examination revealed mild pallor and left sided massive pleural effusion that re-accumulated despite treatment. PAP stained smear of pleural fluid showed a large number of plasma cells and pleural biopsy revealed infiltration of plasma cells. Fiber-optic bronchoscopy was inconclusive. Blood examination revealed high value of alpha-2 globulin. Serum electrophoresis showed M band in alpha-2 region and urine electrophoresis showed faint monoclonal light chain pattern. X-ray skull showed multiple punched out osteolytic lesions. Bone marrow examination revealed hypercellular marrow with atypical plasma cells including binucleate forms in large number (above 55% of nucleated cell population).

Unsuspected multiples myeloma presenting as bilateral pleural effusion - a cytological diagnosis

Background

Multiple Myeloma presenting as a pleural effusion is extremely rare. It is usually a late complication and is associated with a poor prognosis.

Case Presentation

A 40-year-old male presented with dyspnea and fever of six months duration. Clinical diagnosis of pulmonary tuberculosis was considered. X-ray chest showed bilateral pleural effusion. Pleural cytology revealed numerous plasma cells, some of which were binucleated and atypical. Cytological differential diagnosis included: Myelomatous effusion and Non-Hodgkin's Lymphoma deposit (Immunoblastic type). Bone marrow biopsy, serum protein electrophoresis and bone scan confirmed the diagnosis of multiple myeloma (Plasmablastic type).

Conclusion

Myelomatous pleural effusion as an initial presentation although extremely rare, should always be considered in presence of atypical plasma cells irrespective of age.

Pleural Effusions in Hematologic Malignancies

Nearly all hematologic malignancies can occasionally present with or develop pleural effusions during the clinical course of disease. Among the most common disorders are Hodgkin and non-Hodgkin lymphomas, with a frequency of 20 to 30%, especially if mediastinal involvement is present. Acute and chronic leukemias, myelodysplastic syndromes, are rarely accompanied by pleural involvement. Furthermore, 10 to 30% of patients receiving bone marrow transplantation develop pleural effusions. In cases of hematologic pleural effusions, drug toxicity, underlying infectious, secondary malignant or rarely autoimmune causes should be carefully sought. In most cases, the pleural fluid responds to treatment of the primary disease, whereas resistant or relapsing cases may necessitate pleurodesis.