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A Clinicopathological spectrum of myeloma with varied presentations

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Research Article

A Clinicopathological
linicopathological spectrum of multifaceted
myeloma with varied presentations
Gudeli Vahini1*, Inuganti V
Venkata Renuka2, Piddakala Premalatha3, Vaddanti Tejaswini4,
R Krishna5
1 2,5 3 4
Assistant Professor, Professor, Professor and Head, Associate Professor, Department of Pathology, NRI Medical College,
C Mangalagiri,
Vijayawada, Andhra Pradesh, INDIA.
Email: gudelivahini@yahoo.co.in

Abstract Introduction: To analyze the varied clinical presentation and laboratory findings of twenty eight cases of multiple
myeloma received in NRI medical college over a period of two years. Methods: Based on Salmon-Durie
Salmon criteria twenty
eight patients diagnosed as multiple myeloma were selected for the study. The study includes clinical presentation along
with routine hematological and biochemical investigations including bone marrow examination. The radiological
investigations were also included in the spectrum. Results: Out of twenty eight patients, thirteen were males and fifteen
were females with fifth decade as the common age group of presentation. A variety of clinical presentations were seen
including asymptomatic indolen
indolentt case diagnosed in routine checkup, young age of onset, presenting as intracranial space
occupying lesion, generalized weakness, fever, anemia, congestive cardiac failure, ischemic heart disease, varicose veins,
hepatosplenomegaly, acute renal failure, in addition to usual features like bone pains, fractures and osteolytic lesions. All
patients had ‘M band’ on serum electrophoresis, whereas twenty percent patients had urinary Bence Jones proteins. Skull
and pelvis were the common sites of osteolytic lesion lesions. Conclusions: Our study highlights the younger age of
involvement and varied presentations like acute renal failure, ischemic heart disease, congestive cardiac failure, varicose
veins, organomegaly and intracranial space occupying lesion etc. The clinici clinicians
ans should emphasize on thorough
investigation of cases suspicious of myeloma, but with atypical clinical presentation.
Key words:: Bone pains, Bence jones protein, Myeloma, M band.
*
Address for Correspondence:
Dr. Gudeli Vahini, Assistant Professor, Department of Pathology NRI Medical College, Mangalagiri, Vijayawada, Andhra Pradesh, INDIA.
Email: gudelivahini@yahoo.co.in
Received Date: 11/04/2015 Revised Date: 20/04/2015 Accepted Date: 23/04/2015

disease of elderly with peak age of 60-70 60 yrs at

Access this article online presentation. However, an aggressive clinical course has
Quick Response Code: been reported in a very few young patients. patients 1
Website: Complications such as renal failure, infections,
infections anemia,
www.statperson.com lytic bone lesions and amyloidosis lead to morbidity as
well as mortality.2 Though the disease is uniformly fatal,
newer advances in treatment like autologous
hematopoietic stem cell transplantation and advances in
DOI: 26 April 2015 chemotherapy have improved the quality of life and
increased survival.1 Hence this study was undertaken to
evaluate the clinical profile of multiple myeloma.

INTRODUCTION MATERIALS AND METHODS

Multiple myeloma is a disorder caused by neoplastic This was a cross-sectional
sectional study conducted over a period
proliferation of a clone of malignant plasma cells. The of two years in NRI medical college. Patients admitted
adm in
characteristic features include accumulation of medical wards with features of bone pains, anemia and
monoclonal plasma cells in the bone marrow associated lytic bone lesions were included. Detailed history was
with monoclonal immunoglobulin (Ig) synthesis and taken and clinical examination was performed.
osteolytic bone lesions. It comprises 13% of Hematological investigations such as Hemoglobin (Hb)
hematological malignancies. Multiple myeloma is a estimation, total and differential cell counts, erythrocyte

How to site this article: Gudeli Vahini, Inuganti Venkata Renuka, Piddakala Premalatha, Vaddanti Tejaswini, R Krishna.
Krishna A
Clinicopathological spectrum of multifaceted myeloma with varied presentations
presentations. International Journal
al of Recent Trends in Science and
a
Technology April 2015; 14(3): 709-712 http://www.statperson.com (accessed 28 April 2015).
International Journal of Recent Trends in Science And Technology, ISSN 2277-2812 E-ISSN 2249-8109, Volume 14, Issue 3, 2015 pp 709-712

sedimentation rate (ESR), platelet count, peripheral blood Radiological investigations included skeletal survey:
smear, bone marrow examination were done. Urine was imaging studies like magnetic resonance imaging were
examined for Bence jones protein. Serum protein performed where indicated. Diagnosis of multiple
electrophoresis to detect M band was done in all. myeloma was based on Salmon- Durie criteria.3,4

RESULTS AND OBSERVATIONS

Table 1: Age wise distribution of Patients
Sex
Age Group (Years) Total%
Male % Female %
<40 - - -
41-50 4(36.3%) 7(63.6%) 11(39.28%)
51-60 3(33.3%) 6(66.6%) 9(32.14%)
61-70 6(85.7%) 1(14.28%) 7(25%)
>70 - 1(100%) 1(3.5%)

Table 2: Bone marrow examination (% plasma cells)

% Of plasma cells No. of patients Percentage
<30 3 11%
30-40 6 21%
41-50 2 7%
51-89 9 32%
90 5 18%
>90 3 11%

Figure 1 Figure 2 Figure 3

Figure 4 Figure 5

Legend:
Figure 1 and Figure 2: HPE (100X) Mott cells, plasmablasts
Figure 3: X Ray skull shows multiple punched out lesions.
Figure 3 and Figure 4: Clinical presentations of myeloma

International Journal of Recent Trends in Science And Technology, ISSN 2277-2812 E-ISSN 2249-8109, Volume 14, Issue 3, 2015 Page 710
 Gudeli Vahini, Inuganti Venkata Renuka, Piddakala Premalatha, Vaddanti Tejaswini, R Krishna

Out of 28 patients, 13 were males (46%) and 15 were studies.5 Blade et al. reported a series of 72 patients with
females (54%). Fifth decade was the common age group Multiple myeloma younger than 40 and 30 years
at presentation in both genders. Mean age of the patients respectively.7 Two cases in our study were 43 and 42
in our study population was 56 years. One of the patient years females. It has been mentioned that approximately
was 70 years and one was 72 years of age. Common 2% of cases of MM are younger than 40 years and it is
clinical presentations were bone pains (18% ), fever still rare in patients younger than 30 years.6 We did not
(14%), generalized weakness and fatigue (11% ), motor have any cases below 30 years of age. Our study showed
weakness of lower limbs in patients(11%), shortness of slight female preponderance. The most common
breath(18%), hematemesis (7%), fractures (7% ),benign symptoms observed were bony pains (18% ), which are
prostatic hyperplasia with acute renal failure(14%), acute higher compared to other studies, which include
on chronic pyelonephritis (7%), congestive cardiac failure backache, hip, joint, shoulder, neck pain. In some
(3%),coronary artery disease (3%), osteolytic lesions patients, (18%) pain was associated with bony swelling at
(28%), back pain (3%), abdomen pain (3%),intracranial various sites such as sternum, clavicle, skull and left foot.
space occupying lesion(3%), varicose veins (3%), Generalised weakness and fatigue were other presenting
giddiness (3%), blackouts (3%), epistaxis (3%) whereas 4 symptoms (11%) which are comparable to other studies.8
patients had malena (14%). Clinical examination revealed Majority of the (96%) patients were anemic. Normocytic
pallor in 3 patients (11%), bony tenderness (18%), 5 cases anemia was observed in 11 cases (39% ), 10 patients had
had bony swelling (18%), hepatomegaly(18%), hemoglobin below 6.7 g/dl, which is comparable to other
splenomegaly (14%), 1 patient presented with studies.5,8 The mechanism of anemia in most is
pedaledema (3%), gum bleeding was observed in one inadequate red blood cells production due to either
patient (3% ). Hematological features were anemia in erythropoietin deficiency from the accompanying renal
most of the (27) cases (96%), median Hemoglobin failure or replacement of the marrow by myeloma cells.
concentration was 6.7 g/dl and elevated ESR was present In some patients, anemia is disproportionate to renal
in almost all (27)(96% ) cases. Rouleaux formation was failure or marrow involvement and is thought to be
observed in 14 patients (50%), white blood cell count was related to cytokine mediated marrow suppression. The
less than 5,000 /cmm in 4 patients (14% ) and platelet incidence of renal failure in our study was high (14.2%),
count was less than 1.0 lakh/mm3 in six patients ( 21 %) in contrast to other studies.8 Renal function impairment is
and greater than 4 lakhs /mm3 in 1 patients(3%). Serum a common phenomenon in Multiple myeloma: the major
creatinine of more than 1.3 mg/dl was seen in 13 patients causes being myeloma kidney, hypercalcemia and
(46%) at presentation and hypercalcemia was observed in dehydration. In our study all cases demonstrated
9 patients (32%). All patients (100%) had presence of M monoclonal protein. Our further categorization of
band on serum electrophoresis and gamma region was the myeloma there was M band on serum electrophoresis in
most frequent location of the monoclonal band.Twenty gamma region similar to Kyle study. Serum
percent of the patients had urinary Bence jones protein electrophoresis study revealed M band in 100% of
positive.Among skeletal involvement, 8 patients (28 %) patients. In our study, we did not find M band in other
had osteolytic lesions, 4 patients (14.2%) had regions.8 Like Kyle et al. study two spikes (biclonal) were
pathological fractures. Skull and pelvis were the common not found in any patients.
sites of involvement in 14 % and 10 % of cases
respectively. Bone marrow examination revealed the CONCLUSION
presence of more than 90 % plasma cells in 3 cases (11 Our study highlights the younger age of involvement and
%), 5 patients ( 18% ) had 90 %, 6 patients ( 21% ) had varied presentations like acute renal failure, ischemic
plasma cells in the range of 30-40%, 1 patient (3%) had heart disease, congestive cardiac failure, varicose veins,
45% and 1 (3%) had 15% of plasma cells. According to organomegaly and intracranial space occupying lesion
Durie-Salmon staging, Stage III was most common stage etc. The clinicians should emphasize on thorough
at presentation. In our study 22 patients (78%) presented investigation of cases suspicious of myeloma, but with
in stage III, 5 patients (18%) presented in stage II. atypical clinical presentation.

DISCUSSION ACKNOWLEDGEMENT
Multiple myeloma is a hematological malignancy usually My special regards to the Principal( Dr. Chowdary) NRI
presenting in the elderly, with a median age in India of Medical college and to all my professors (Dr. Krishna,
55-60 years. In the present study, 20 patients were 60 and Dr. P. Premalatha) to make this paper work successful.
below 60 years of age and maximum number of cases Most grateful and thankful to Dr. I. V. Renuka
were between 45 and 60 years, which is similar to other (Professor) without which this paper could never happen.

Copyright © 2015, Statperson Publications, International Journal of Recent Trends in Science And Technology, ISSN 2277-2812 E-ISSN 2249-8109, Volume 14, Issue 3 2015
 International Journal of Recent Trends in Science And Technology, ISSN 2277-2812 E-ISSN 2249-8109, Volume 14, Issue 3, 2015 pp 709-712

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Source of Support: None Declared

Conflict of Interest: None Declared

International Journal of Recent Trends in Science And Technology, ISSN 2277-2812 E-ISSN 2249-8109, Volume 14, Issue 3, 2015 Page 712

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