Presentation of Multiple Myeloma as Bilateral Pleural Effusions-significance of Obtaining Pleural Fluid Cytology

Document Type

Conference Proceeding

Publication Date

5-21-2023

Publication Title

American Journal of Respiratory and Critical Care Medicine

Abstract

Introduction: Pleural effusion is a common clinical finding seen in a variety of diseases such as heart failure, pneumonia, malignancy, and pancreatitis among others. The presence of myelomatous pleural effusion (MPE) is rare and represents less than 1% of patients with multiple myeloma (MM). We present a patient who came to the hospital with shortness of breath, was found to have plasma cells in pleural effusion which enabled further investigations leading to the diagnosis of multiple myeloma. Case presentation: A 67-year-old gentleman with a past medical history of deep venous thrombosis on anticoagulation presented to the emergency room after being sent by his primary care doctor due to worsening kidney function and bilateral pleural effusions on the chest-x-ray. The patient had gradual onset shortness of breath, orthopnea, and new onset weight gain for the last few months. On examination, he had stable vital signs and no breath sounds on the right lower lung fields. Laboratory findings were consistent with new-onset anemia with hemoglobin of 9.7 grams/deciliter. His creatinine was elevated at 2.37 mg/dL (milligrams/deciliter) with a normal value of 1.1 mg/dL one year ago. CT (Computed Tomography)-chest showed moderate-sized bilateral pleural effusions (figure). Thoracentesis was performed on the left side which returned 2 liters of straw-colored pleural fluid. Fluid was noted to be exudative, and the cytology showed plasmacytoid cells concerning plasma cell disorder. Due to worsening kidney function, kidney biopsy was done which showed lambda chain cast nephropathy. The monoclonal protein screen showed elevated lambda light chains with free light chain ratio of 0.0. Bone marrow biopsy was obtained which was consistent with the diagnosis of multiple myeloma. The patient required another thoracentesis for the right-sided pleural effusion which also showed exudative pleural fluid and plasmacytoid cells on cytology. The patient followed up with Hematology and was started on appropriate chemotherapy. Discussion: Pleural effusion in multiple myeloma (MM) is usually secondary to pneumonia, renal insufficiency, congestive heart failure, and amyloidosis. MPE is a rare presentation of MM. The rarity of this condition might delay the diagnosis of MM, increasing the need for awareness of MPE as the sole presenting feature of MM. This necessitates ordering pleural fluid cytology studies, especially in a patient with suspected malignancy which can enable clinicians to pursue further diagnostic tests for its confirmation. (Figure Presented).

Volume

207

Issue

1

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