A rare case of pulmonary plasmacytoma secondary to multiple myeloma.
Rezik M, Onyenekwe J, Farha R, and Ouellette D. A rare case of pulmonary plasmacytoma secondary to multiple myeloma. Chest 2016; 150(4):1093A.
Multiple myeloma is a neoplastic proliferation of plasma cells that occurs within the bone marrow. Uncommonly, proliferation may occur within other tissues in the form of extramedullary plasmacytomas. We report a very rare case of rapidly progressive pulmonary multiple myeloma. CASE PRESENTATION: A 50-year-old female presented for worsening right lower extremity swelling. She admitted to mild nonproductive cough without dyspnea, chest pain, fever or chills. Physical exam revealed bilateral lower extremity edema, right greater than left, without erythema. Cardiovascular exam was benign. Medical history was significant for multiple myeloma was diagnosed 6 years prior that had been refractory to multiple chemotherapy regimens and stem cell transplants. She had progression of her disease resulting in cord compression and resultant paraplegia. A CT scan of the abdomen was done to evaluate for possible pelvic vein compression and revealed worsening of known pulmonary nodules first seen six months prior. CT scan of the chest confirmed innumerable diffuse bilateral pulmonary nodules throughout the lungs that had incrased in both size and number with new patchy ground-glass opacities and extensive mediastinal lymphadenopathy. A transbronchial tissue biopsy via bronchoscopy was performed to determine the etiology of her lung nodules prior to initiation of chemotherapy. This was complicated by uncontrolled bleeding and hypoxia leading to cardiac arrest. The patient was successfully resuscitated and transferred to the intensive care unit for further management. Pathology of the right upper lobe revealed plasma cell neoplasm consistent with multiple myeloma. Prior to receiving chemotherapy, the patient's family decided to pursue comfort care only and the patient expired shortly afterwards. DISCUSSION: Primary extramedullary plasmacytomas, while rare, commonly occur in the airways and upper pharynx. However, while extramedullary involvement of multiple myeloma can be seen in an estimated 13% of patients, pulmonary spread is extremely rare. To the best of our ability, a search of the literature revealed three prior cases of multiple pulmonary nodules occurring in multiple myeloma. Other manifestations of pulmonary involvement in multiple myeloma include pneumonia, mass lesion, interstitial disease and calcification. CONCLUSIONS: Extramedullary spread of multiple myeloma to the lung is uncommon and very rarely manifests in the form of pulmonary nodules. The presence of extramedullary disease at the time of diagnosis, occurring in over half of extramedullary cases of myeloma, has been associated with poor survival. This is in contrast to the longer survival rates reported with primary pulmonary plasmacytomas. Therefore, the etiology of pulmonary nodules found in patients with multiple myeloma must be determined to ensure adequate and timely therapy.