Salguero Douglas A, Barletta Pamela A, Sierraalta Willaim
Advance Simulation Center, University of Francisco Marroquin-UFM, 6 avenue zone 10, 01011, Guatemala, Guatemala.
Universidad Latina de Panama, Panama City, Panama.
J Med Case Rep. 2018 Mar 18;12(1):70. doi: 10.1186/s13256-018-1598-y.
Multiple myeloma is a hematologic disease with high mortality rates all over the world. The diagnosis has always been challenging since the first case was reported in 1844. For that reason the diagnostic criteria have evolved over years to include the features of the disease more comprehensively. Unusual presentations are infrequent and a diagnostic challenge. For this reason we report this rare case in which diarrhea and abdominal pain were the initial presenting symptoms of multiple myeloma with a plasmacytoma.
An 87-year-old Hispanic man with a past medical history of hypertension, diabetes, and constipation, presented to an emergency department complaining of severe generalized abdominal pain and profuse diarrhea for 3 days. A physical examination revealed generalized pallor and dehydration but no signs of abdominal peritoneal irritation. Laboratory tests revealed neutrophilia and an elevated total protein. He received intravenously administered fluids and antibiotics. His abdominal pain became localized in the infraumbilical area and a small mass was palpated on the right lower quadrant on subsequent examination. An abdominal computed tomography scan showed a tumor lesion surrounded by fluid collection and a computed tomography-guided biopsy of the lesion confirmed it to be a plasmacytoma. A bone marrow biopsy revealed plasmatic cell augmentation but his beta-2 microglobulin levels were inconclusive. The diagnosis of multiple myeloma was finally confirmed with urine immunofixation. Bortezomib was initiated to decrease disease progression, but unfortunately 4 days later he developed acute pulmonary edema, had a cardiac arrest, and died.
This case illustrates the protean initial manifestations of multiple myeloma and the importance of an accurate diagnosis. Our patient's initial presentation with gastrointestinal complaints is rare and the plasmacytoma location is even rarer, providing a challenging diagnostic problem. Prompt recognition of multiple myeloma is critical to institute appropriate therapy and prevention of disease progression.
多发性骨髓瘤是一种在全球范围内死亡率很高的血液系统疾病。自1844年首例病例报告以来，其诊断一直具有挑战性。因此，多年来诊断标准不断演变，以更全面地涵盖该疾病的特征。不寻常的表现并不常见，是诊断上的一个挑战。因此，我们报告这例罕见病例，其中腹泻和腹痛是伴有浆细胞瘤的多发性骨髓瘤的初始表现症状。
一名87岁的西班牙裔男性，有高血压、糖尿病和便秘病史，因严重的全身性腹痛和大量腹泻3天就诊于急诊科。体格检查发现全身苍白和脱水，但无腹部腹膜刺激征。实验室检查显示中性粒细胞增多和总蛋白升高。他接受了静脉补液和抗生素治疗。随后检查发现他的腹痛局限于脐下区域，右下腹可触及一个小肿块。腹部计算机断层扫描显示一个肿瘤病变被液体包裹，对该病变进行计算机断层扫描引导下活检证实为浆细胞瘤。骨髓活检显示浆细胞增多，但他的β2微球蛋白水平不明确。最终通过尿免疫固定确诊为多发性骨髓瘤。开始使用硼替佐米以减少疾病进展，但不幸的是，4天后他出现急性肺水肿，心脏骤停并死亡。
本病例说明了多发性骨髓瘤多变的初始表现以及准确诊断的重要性。我们的患者以胃肠道症状为初始表现很罕见，浆细胞瘤的位置更是罕见，这提供了一个具有挑战性的诊断问题。及时识别多发性骨髓瘤对于制定适当的治疗方案和预防疾病进展至关重要。
