Age Is Just a Number: A Case of Multiple Myeloma in a 29 Year Old Male
Location
Medical Education Building, LSUHSC-NO
Presentation Date
10-10-2019 10:00 AM
End Date
10-10-2019 12:00 PM
Description
Case: A 29-year-old Hispanic male with hyperlipidemia presented to the emergency department complaining of left sided chest pain for 6 months. Starting as a mild pain, the patient reported progression to severe pain localized to the left posterior rib cage. It was aggravated by movement to the point of preventing him from performing his job as a construction worker for the past 2 months. He also reported new pain in his lower back and sternum over that same time period. These additional intermittent episodes of pain had also progressed from mild to severe. When present, his back pain prevented him from standing. He was concerned for swelling at the center of his chest. The patient reported no bowel or bladder incontinence, but did report fatigue, malaise, night sweats, and a recent eight-pound weight loss. He reported no IV drug use and a noncontributory family history, including no cancer. Physical exam was remarkable for peristernal swelling and multiple areas tender to palpation, including left ribs, sternum, and the thoracic and lumber paraspinal muscles. Laboratory evaluation revealed mild normocytic anemia, decreased anion gap, and elevated total protein with elevated protein gap. Initial imaging demonstrated multiple lytic lesions along with multiple pathologic rib fractures bilaterally. After an initial bone marrow biopsy was inconclusive, a sternal biopsy showed the confirmatory diagnosis of multiple myeloma. Discussion: Multiple myeloma is a disease of plasma cell proliferation. It is coined a “disease of elderly” as the median age at diagnosis is 66 years old. Less than 10% of cases are in patients under 50 years old, while less than 2% of the total patients are under 40. African Americans have the highest risk, while Japanese and Hispanics are at lower risk. This case is clinically interesting as the patient was far below the expected age in addition to being low risk based on his ethnicity. Most commonly presenting as either unexplained anemia or new bone pain, patients can also present with signs and symptoms of renal disease, hypercalcemia, and nerve compression. Laboratory findings include normochromic normocytic anemia, hypercalcemia, elevated creatinine level, decreased or negative anion gap, and have an M spike on SPEP. Imaging may show lytic bone lesions and pathologic fractures. Criteria for diagnosis includes either a bone marrow biopsy with 10+% plasma cells or a biopsy showing a plasmacytoma along with related organ/tissue impairment. These classic findings are known by the mnemonic ‘CRAB’ (hyperCalcemia, Renal involvement, Anemia, Bone lesions). Due to the heterogeneity of this disease, management is tailored based on staging and prognosis of the patient. This atypical case of multiple myeloma illustrates the importance of not excluding a disease from a differential based solely on epidemiology.
Recommended Citation
Morreale, Peter and Savoie, Blake MD, "Age Is Just a Number: A Case of Multiple Myeloma in a 29 Year Old Male" (2019). Medical Student Research Poster Symposium. 29.
https://digitalscholar.lsuhsc.edu/sommrd/2019/posters/29
Age Is Just a Number: A Case of Multiple Myeloma in a 29 Year Old Male
Medical Education Building, LSUHSC-NO
Case: A 29-year-old Hispanic male with hyperlipidemia presented to the emergency department complaining of left sided chest pain for 6 months. Starting as a mild pain, the patient reported progression to severe pain localized to the left posterior rib cage. It was aggravated by movement to the point of preventing him from performing his job as a construction worker for the past 2 months. He also reported new pain in his lower back and sternum over that same time period. These additional intermittent episodes of pain had also progressed from mild to severe. When present, his back pain prevented him from standing. He was concerned for swelling at the center of his chest. The patient reported no bowel or bladder incontinence, but did report fatigue, malaise, night sweats, and a recent eight-pound weight loss. He reported no IV drug use and a noncontributory family history, including no cancer. Physical exam was remarkable for peristernal swelling and multiple areas tender to palpation, including left ribs, sternum, and the thoracic and lumber paraspinal muscles. Laboratory evaluation revealed mild normocytic anemia, decreased anion gap, and elevated total protein with elevated protein gap. Initial imaging demonstrated multiple lytic lesions along with multiple pathologic rib fractures bilaterally. After an initial bone marrow biopsy was inconclusive, a sternal biopsy showed the confirmatory diagnosis of multiple myeloma. Discussion: Multiple myeloma is a disease of plasma cell proliferation. It is coined a “disease of elderly” as the median age at diagnosis is 66 years old. Less than 10% of cases are in patients under 50 years old, while less than 2% of the total patients are under 40. African Americans have the highest risk, while Japanese and Hispanics are at lower risk. This case is clinically interesting as the patient was far below the expected age in addition to being low risk based on his ethnicity. Most commonly presenting as either unexplained anemia or new bone pain, patients can also present with signs and symptoms of renal disease, hypercalcemia, and nerve compression. Laboratory findings include normochromic normocytic anemia, hypercalcemia, elevated creatinine level, decreased or negative anion gap, and have an M spike on SPEP. Imaging may show lytic bone lesions and pathologic fractures. Criteria for diagnosis includes either a bone marrow biopsy with 10+% plasma cells or a biopsy showing a plasmacytoma along with related organ/tissue impairment. These classic findings are known by the mnemonic ‘CRAB’ (hyperCalcemia, Renal involvement, Anemia, Bone lesions). Due to the heterogeneity of this disease, management is tailored based on staging and prognosis of the patient. This atypical case of multiple myeloma illustrates the importance of not excluding a disease from a differential based solely on epidemiology.