J Hematol

Journal of Hematology, ISSN 1927-1212 print, 1927-1220 online, Open Access

Article copyright, the authors; Journal compilation copyright, J Hematol and Elmer Press Inc

Journal website http://www.thejh.org

Case Report

Volume 2, Number 1, June 2013, pages 42-47

Unconventional Presentation of Multiple Myeloma: A Series of 4 Cases

Figures

Figure 1. X-ray chest PA view showing a homogenous opacity in right middle lobe. Inset CT scan showing mass in right lung extending in thoracic cage.

Figure 2. Tongue showing macroglossia. Inset biopsy tongue showing hyperplastic epithelium, atrophic muscle fibres and hyaline eosinophilic substance (H&E stain × 200).

Figure 3. Renal biopsy showing obliteration of glomerular architecture by accumulation of amyloid and eosinophilic hyaline cast in tubules (PAS stain × 200).

Figure 4. a). Serum Protein Electrophoresis showing “M” Spike in gamma globulin region. b). Serum Immunofixation Electrophoresis (IFE) identified the “M” spike as IgG and Kappa.

Figure 5. CT thoracic spine: sagittal view-showing multiple punched out lytic lesions in vertebral bodies and compression fracture of T9 vertebral body (arrow).

Figure 6. Bone marrow aspirate showing plasmacytosis (Leishman stain × 200).

Table

**Table 1.** Clinical Details of the Patients
Parameters	Normal range	Case 1	Case 2	Case 3	Case 4
Kappa: κ; Lambda: λ; Bence Jones protein: BJ; ESR: by Wintrobe’s.
Haematological
Hb (g/dL)	13.5 - 15.5	9.6	10.2	7.0	10.2
TLC (× 10⁹/µL)	4.0 - 11.0	9.8	8.5	10.5	6.7
Platelet (× 10⁹/µL)	150 - 400	220	200	310	250
ESR (mm in 1st hr)	0 - 14 (M) 0 - 20 (F)	60	50	10	18
Blood Picture		Normocytic normochromic	Normocytic normochromic	Microcytic hypochromic	Normocytic normochromic
Bone marrow (% plasma cells)	0.1 - 3.5	10	60	38	80
Biochemical
Urea (mg/dL)	10 - 50	35	42	103	38
Creatinine (mg/dL)	0.7 - 1.3	0.8	0.9	15	1.0
Total protein (g/dL)	6.0 - 8.3	7.8	7.0	7.8	6.8
Albumin (g/dL)	3.5 - 5.7	4.2	4.0	3.4	3.8
Calcium (mg/dL)	8.5 - 10.5	10.0	10.2	9.8	9.6
IgG (g/dL)	6.94 - 16.2	17.1	12.2	20.1	13.1
IgA (g/dL)	0.80 - 4.00	2.38	2.52	1.52	2.18
IgM (g/dL)	0.50 - 2.00	0.82	1.22	0.92	0.62
κ:λ ratio	0.26 - 1.65	2.42	0.8	2.54	1.45
Urine total protein (mg/24 hours)	150	No BJ	3000, M protein κ	2400	No BJ
Amyloid		Negative	Positive	Positive	Negative
Monoclonal band		M band, IgG κ in serum	M band in urine, free κ light chain	M band IgG κ in serum and urine	No M band in urine/serum