HISTORY• 55 year old male presents with:

• CHIEF COMPLAINS:• On and off fever × 10 months• Pain in the nape of the neck × 7-8 months

A CASE OF FEVER WITH BONY PAINS

-Arpita Khasnavis MBBS 2011

HISTORY OF PRESENTING ILLNESS

FEVERDuration :10 months, on and off type, associated

with night sweats, no diurnal variation, not associated with rigors and chills.

relieved by antipyretics to reoccur a few days later.

Was associated with weight loss.

PAINH/O pain in the nape of neck for the last 7-8

months, started abruptly, having moderate intensity.

Dull and persistent pain, aggravated by movement around the neck with minimum relief with medication, no radiation.

EXAMINATIONBody weight: 51 kg, Height: 1.75 m BMI: 16.6kg/m2

Oriented to time, place and person.B.P: 116/ 72 mm Hg, H.R.:88/min.

P⁺/I⁻/Cy⁻/Cl⁻/LAP⁻/PE⁻/JVP(N)

Respiratory system: ◦ B/L vesicular breathing, no adventitious sounds

heard. ◦ mass was palpable near the 4th rib on right

side.

Rest of the systemic examination was unremarkable.

Description of the mass near 4th rib

1. Location 4th rib, mid clavicular line

2. Shape and size Circular, diameter approx. 4cm

3. Visible on inspection

No, only palpable

4. Tenderness Present

5. Edges Irregular

6. Consistency Firm

7. Mobility Absent

8. Adherence Present to underlying bone

Lab Investigations

Hemoglobin

7.8 g/dl

Total leucocyte count

6000/cmm

Differential leucocyte count

78/18/2/2

Absolute platelet count

1 lac/cmm

ESR 122mm/hr

Possibility of a lesion on 4th rib.

X-RAY CHEST: A-P VIEW TO CHECK FOR ANY LESION IN THE RIBS

C.T. SCAN SHOWING SOFT TISSUE WINDOW

Lytic areas with enhancing soft tissues on multiple vertebrae, ribs.

AXIAL SCAN:Large soft tissue component of intermediate density extending on right side. Involvement of posterior aspect is better appreciated.

SAGITTAL SCAN:Altered marrow signal density in T1 extending in right sided posterior element which shows intermediate signal density on T1 and T2

M.R.I

FINE NEEDLE ASPIRATION CYTOLOGY OF PALPABLE MASS :

Positive for malignancy.Possibility ranking high in the order being

multiple myeloma.

BONE MARROW ASPIRATION:

Marrow shows prominent plasma cells >20%. Other normal hematopoietic elements are reduced.

Plasmacytoma to be co-related with radiological findings and serum electrophoresis.

Biochemical ExaminationTEST NAME RESULT NORMAL VALUE

Serum protein 13.3 g/dl 6.00-8.00 g/dl

A/G ratio 0.6 2:1

Gamma globulin 6.92 g/dl 0.60-1.60 g/dl

Myeloma bands M bands

Urine examination:• Bence jones

proteins

Present Absent

Serum protein electrophoresis shows a prominent M band at the junction of Beta 2 and Gamma region in the background of hypergammaglobulinemia

Differential DiagnosisMultiple Myeloma Waldenstrom

Macroglubulinemia

Hepatospleenomegaly

__ +

Lymphadenopathy __ +

Hyperviscosity __ +

Bence jones proteins in urine

More commonly seen Less commonly seen

Coomb’s test +ve Less commonly seen More commonly seen

Bony Lesions More common Less Common

Diagnostic Criteria for MULTIPLE MYELOMA

MAJOR CRITERIA

I = Plasmacytoma on tissue biopsy.

II = Bone marrow with greater than 30% plasma cells.

III = IgG peak of greater than 3.5 g/dL or an IgA peak of greater than 2 g/dL, or urine protein electrophoresis (in the presence of amyloidosis) result of greater than 1 g/24 h

MINOR CRITERIA

a = Bone marrow with 10-30% plasma cells.

b = Monoclonal globulin spike present but less than category III

c = Lytic bone lesions

d = Residual IgM level less than 50 mg/dL, IgA level less than 100 mg/dL, or IgG level less than 600 mg/dL

The following combinations of findings are used to make the diagnosis of multiple myeloma:

I plus b, c, or d

II plus b, c, or d

III plus a, c, or d

a plus b plus c

a plus b plus d

MANAGEMENTChemotherapy.High dose chemotherapy or Bone marrow or

stem cell transplantation may be done. The 2011 NCCN MM guidelines added the

following therapies : Combination of:

1 Bortezomib/ cyclophosphamide/dexamethasone (primary induction therapy for transplant patients)

2 Bortezomib/dexamethasone (primary induction therapy for those who are not candidates for transplantation)

3 Melphalan/prednisone/lenalidomide (primary induction therapy for non transplant patients)

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