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Wednesday, 4 December 2013

Multiple myeloma- Misdiagnosis

Multiple myeloma, also known as plasma cell myeloma or Kahler’s disease, is a type of abnormal growth of plasma cells collected in the bone marrow where they grow and multiple to interfere with the production of normal blood cells. Paraprotein, an abnormal antibody produced by the plasma cell myeloma not only can cause kidney problem but also interference with the Roche automated total bilirubin assay by precipitate formation of that can lead to clinical confusion, according to the study by the Harvard Medical School, Boston(1). Other study indicated that the production of paraproteins caused spurious results on individual analytes including total bilirubin (TBIL), direct bilirubin (DBIL), or HDL-cholesterol (HDL-C)(b). There is also a report of a 50 years old
chloride resistant metabolic alkalosis in a patient with hypercalcemia related to Multiple Myeloma (MM)(c).
A. Misdiagnosis
1. Spinal epidural metastasis
There is a report of a 42-year-old man presented with a one-month history of upper back pain and a two-week history of progressive spastic paraparesis. Thoracic spinal MRI showed an epidural mass with spinal cord compression at T6-8 but no bony involvement. The patient underwent T6-8 laminectomy for decompression. Lumbosacral MRI and CT scans revealed bony abnormalities on the sacrum and left posterior iliac bone. Immunohistochemical studies confirmed the diagnosis of multiple myeloma (MM)(28).
2. Orbital mass
There is a report of a case of a 28-year-old African-American woman presented with new onset of left exophthalmos and diplopia with initially vomputed tomography of the head showed a solitary mass in the left orbit, But excisional biopsy revealed a diffuse infiltrate composed of exclusively λ-restricted monotypic plasma cells based on morphology and immunohistochemistry, consistent with a plasma cell neoplasia. A subsequent staging bone marrow biopsy showed involvement of the bone marrow by λ-restricted monotypic plasma cells, consistent with a plasma cell myeloma. Serum protein electrophoresis and immunofixation studies on the peripheral blood showed a monoclonal band of IgE-λ; thus, an IgE-λ plasma cell myeloma(29).
3. Acute liver diseases
According to the study by St. Vincent’s Comprehensive Cancer Center, there is a report of a case of a 55-year-old woman with MM who presented with painless jaundice, mild pruritus, and abnormal liver function tests resembling acute cholestatic hepatitis without the stigmata of chronic liver disease, but clinical manifestations of liver involvement in multiple myeloma (MM) are uncommon. Rare cases of MM present as acute liver disease(30).
4. Pituitary mass lesion
there is a report of a case of a 71-year-old female patient affected by an extramedullary IgG-lambda multiple myeloma presenting as a pituitary mass lesion. The diagnostic approaches confirmed the diagnosis of multiple myeloma and describe treatment outcome after therapy, according to the study by Medizinische Klinik Campus Innenstadt, Klinikum der LMU(31).
5. Intrasellar plasmacytoma
Plasmacytomas are unusual causes of a sellar mass. Occasionally, they can be misdiagnosed as a nonfunctioning adenoma because of radiological and clinical similarities. there is a report of a 70-year-old woman presented with a recurrent hypophysial mass. Initial diagnosis of a nonfunctioning pituitary adenoma was later overruled by a repeat biopsy, which showed a plasmacytoma. The tumor stained positively for CD138 and kappa light chain(32).
6. Pituitary adenoma
There is a report of a case of multiple myeloma which presented as a solitary intrasellar tumor. The initial radiographic and light microscopic findings were interpreted as being consistent with pituitary adenoma. Subsequently, when systemic disease developed and a bone marrow biopsy demonstrated multiple myeloma(33),
7. Chromophobe adenoma
62-year-old woman presenting with intracranial lesion eroding the sella with compression of optic chiasma was found to have plasmacytoma of the pituitary area. At the time of initial surgery, the patient had no biochemical, immunologic or marrow findings of multiple myeloma. The intracranial tumor was interpreted initially as chromophobe adenoma on light microscopy, but the diagnosis of plasmacytoma was established by electron microscopic examination of the tumor(34).
8. Etc.
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Sources
(a) http://www.ncbi.nlm.nih.gov/pubmed/12521367
(28) http://www.ncbi.nlm.nih.gov/pubmed/22898195
(29) http://www.ncbi.nlm.nih.gov/pubmed/23084304
(30) http://www.ncbi.nlm.nih.gov/pubmed/18021472
(31) http://www.ncbi.nlm.nih.gov/pubmed/22851185
(32) http://www.ncbi.nlm.nih.gov/pubmed/18726062
(33) http://www.ncbi.nlm.nih.gov/pubmed/3791987
(34) http://www.ncbi.nlm.nih.gov/pubmed/445346