multiple myeloma ( mm ) is one of the most common hematological malignancies , the majority of which remain incurable .
the common presenting symptoms of mm , such as bone pain , asthenia , fatigue , weight loss , and dyspnea , are nonspecific , which may contribute to the significant delay in the diagnosis in almost half of mm cases after the onset of the first symptom ; furthermore , 20% of patients have no or mild symptoms at the time of diagnosis
. there might be other possible less well - known clinical features associated with mm ; for example , eczema may slightly increase the risk of the igg myeloma subtype .
we report a case where eczema preceded the diagnosis of mm by at least 5 years in the hope of adding confirmatory evidence for the association between eczema and myeloma . with the advancements in the therapeutic approaches to myeloma
, the recognition of early myeloma symptoms would lead to prompt diagnosis and treatment before the development of serious organ damage , and prolong life .
a 68-year - old male presented for progressive loss of appetite and lethargy for 3 weeks .
the past medical history included hypertension , hyperlipidemia , coronary artery disease with multiple percutaneous coronary interventions ( the most recent one was 3 weeks prior to the admission ) , congestive heart failure with automated implantable cardioverter - defibrillator placement , and psoriasis diagnosed 5 years ago .
the patient had a history of smoking one pack of cigarettes per day for 40 years .
there were multiple large erythematous plaques of skin in the bilateral inguinal and axillary and right hip areas weeping serous discharge ( fig .
the laboratory tests showed normal hemoglobin initially , which dropped to 8.5 within 1 month after admission , hypercalcemia , m spike , and elevated 2-microalbumin and igg levels ( table 1 ) .
the ct scan of the head demonstrated multiple  punched out lucencies within the skull ( fig .
bone survey revealed innumerable lytic lesions throughout the visualized bones : cranial vault ( fig .
2b ) , proximal shaft of femur bilaterally , hips , and pelvic bones ( fig . 2c , d ) .
bone marrow core biopsy showed increased plasma cells up to 10% , confirmed on cd138 , with predominance of monoclonal lambda .
skin biopsy revealed epidermal spongiotic dermatitis with acanthosis and parakeratosis , the upper dermis with perivascular lymphocytic exocytosis and rare eosinophils .
in addition , the patient had eosinophilia and elevated ige ( table 1 ) ; atopic eczema was the most likely diagnosis .
mm , one of the most common hematological malignancies , represents 1.4% of all new cancer cases in the united states and accounts for 2% of cancer - related mortality .
although the 5-year survival has been improving , most of the mm cases remain incurable .
in addition , there has been a rise in the incidence of new mm cases of 0.7% each year over the last decade .
the revised criteria for the diagnosis of mm issued by the international myeloma working group ( imwg )   utilize biopsy and clinical clues ( table 2 ) .
the evidence supporting the diagnosis of mm in this case includes : ( 1 ) 10% clonal plasma cells on bone marrow biopsy ( see case description ) ; ( 2 ) corrected calcium above 11 mg / dl ; ( 3 ) although the renal function was normal at admission , the creatinine level reached 3.1 during the hospital course transiently ; ( 4 ) the hemoglobin fell to 8.5 g / dl after admission ( table 1 ) , and ( 5 ) extensive lytic bone lesions on ct and bone survey ( fig .
although not required by the revised imwg diagnostic criteria , the presence of an m spike provides further support of the diagnosis of mm ( table 1 ) .
the levels of 2-microalbumin ( 3.7 mg / l ) and albumin ( 2.7 g / dl ) help classify the mm as stage ii igg lambda mm , according to the international staging system for multiple myeloma ( table 3 ) .
the common presenting symptoms of mm are nonspecific , i.e. bone pain , asthenia , fatigue , weight loss , and dyspnea .
about 20% of patients have no symptoms or mild ones at the time of diagnosis .
more than 40% of mm patients were diagnosed more than 6 months after the onset of the first symptom .
the prolonged delay commonly occurs in patients who first present to their general practitioner and is associated with more complications , advanced stage of malignancy , and reduced disease - free survival .
therefore , it is critical to increase the awareness of myeloma and associated symptoms among medical communities , especially general practitioners .
we report a case of mm where eczema occurred 5 years prior to the diagnosis of mm .
unexplained eczema of adult onset has been reported to be a marker of a variety of hematologic malignancies and solid tumors [ 6 , 7 , 8 ] .
the risk of mm is positively related to the number and duration of inflammatory conditions ; a prior history of eczema has been reported to slightly increase the risk of myeloma .
therefore , in the absence of an identifiable etiology , recalcitrant eczema in an adult should raise the suspicion of an internal malignancy , including mm .
the possibility of mm should be evaluated systematically with meticulous physical examination , complete blood count , blood film , serum protein electrophoresis , chest x - ray , and ct scan of the trunk .
the revised criteria for the diagnosis of mm issued by the international myeloma working group ( imwg )   utilize biopsy and clinical clues ( table 2 ) .
the evidence supporting the diagnosis of mm in this case includes : ( 1 ) 10% clonal plasma cells on bone marrow biopsy ( see case description ) ; ( 2 ) corrected calcium above 11 mg / dl ; ( 3 ) although the renal function was normal at admission , the creatinine level reached 3.1 during the hospital course transiently ; ( 4 ) the hemoglobin fell to 8.5 g / dl after admission ( table 1 ) , and ( 5 ) extensive lytic bone lesions on ct and bone survey ( fig .
although not required by the revised imwg diagnostic criteria , the presence of an m spike provides further support of the diagnosis of mm ( table 1 ) .
the levels of 2-microalbumin ( 3.7 mg / l ) and albumin ( 2.7 g / dl ) help classify the mm as stage ii igg lambda mm , according to the international staging system for multiple myeloma ( table 3 ) .
the common presenting symptoms of mm are nonspecific , i.e. bone pain , asthenia , fatigue , weight loss , and dyspnea .
about 20% of patients have no symptoms or mild ones at the time of diagnosis .
more than 40% of mm patients were diagnosed more than 6 months after the onset of the first symptom .
the prolonged delay commonly occurs in patients who first present to their general practitioner and is associated with more complications , advanced stage of malignancy , and reduced disease - free survival .
therefore , it is critical to increase the awareness of myeloma and associated symptoms among medical communities , especially general practitioners .
we report a case of mm where eczema occurred 5 years prior to the diagnosis of mm .
unexplained eczema of adult onset has been reported to be a marker of a variety of hematologic malignancies and solid tumors [ 6 , 7 , 8 ] .
the risk of mm is positively related to the number and duration of inflammatory conditions ; a prior history of eczema has been reported to slightly increase the risk of myeloma .
therefore , in the absence of an identifiable etiology , recalcitrant eczema in an adult should raise the suspicion of an internal malignancy , including mm .
the possibility of mm should be evaluated systematically with meticulous physical examination , complete blood count , blood film , serum protein electrophoresis , chest x - ray , and ct scan of the trunk .
 multiple myeloma is the fourteenth cause of cancer - related death . 
 the symptoms of myeloma are mostly nonspecific , and there is significant delay between the first symptoms and diagnosis of myeloma . 
 atopic eczema is a common chronic inflammatory skin disease associated with dysregulation of the immune system . 
 it generally develops in early childhood but can also occur in adults . 
 eczema is associated with a variety of hematological and solid malignancies , and possibly multiple myeloma . 
 we report a patient with eczema that developed 5 years before the diagnosis of multiple myeloma but was mistaken for psoriasis . 