A 78-year-old male presented with easy fatigue and awareness of heartbeat 2 weeks before admission. He reported multiple episodes of dizziness and weakness upon exertion. He did not report any history of bleeding from nose, mouth or stool. He did not complain of hematuria or reduced urine output. On examination, he had conjunctiva and palmar pallor with no palpable lymphadenopathy and no icterus. His chest and abdominal examination were relatively normal.
He was initially found to have normocytic, normochromic anemia of 5.3g/dL and platelet count of 49x109/L. The peripheral blood smear did not show any evidence of abnormal morphology. A stool sample showed positive occult blood suspecting the patient to have an upper gastrointestinal (GI) bleeding. An esophagogastroduodenoscopy showed diffuse mucosal pallor with minimal inflammation only. An abdominal ultrasound was relatively normal.
His control hemoglobin was 4.1g/dL after blood transfusion, suspecting ongoing bleeding. A colonoscopy showed clots under the superficial mucosa on different sites with superficial clots and fresh blood throughout the colon which could be explained by thrombocytopenia. Biopsy was not taken due to risk of bleeding. However, lesions in the caecum and terminal ileum could not be ruled out. At this point, he was suspected to have malignancy of the colon or inflammatory bowel disease. The carcinoembryonic antigen was 1.48ng/mL. Further workup showed him to have an INR of 1.3, repeat hemoglobin of 4.7g/dL and repeat platelets of 47x109/L.
His general condition was not improving and had a poor performance status. A C-reactive protein showed 25,005ng/mL (normal 0-700ng/mL) and lactate dehydrogenase of 217.3U/L (normal 240.0-480.0U/L). Part of his liver workup showed serum albumin of 27.4g/L and a serum total protein of 99.7g/L.
Following the elevated serum total protein levels, a serum creatinine and serum calcium were 485micromol/L and 3.91mmol/L, respectively. His skull X-ray showed multiple clear punched-out lesions in the skull bones (Figure 1). An abdominal computed tomography (CT) scan showed no obvious abdominal malignancy but detected osteolytic bone lesions on the thoracolumbar spine and pelvis (Figures 2, 3 and 4). All these lesions were present without reported bone pain. A serum protein electrophoresis showed M component 68g/L, kappa free light chain 16.0mg/L, lambda free light chain 974.0mg/L, kappa/lambda ratio of 0.016 and beta2-microglobulin 33.0mg/L.
Given his poor performance status, he was initiated on cyclophosphamide 75% of the required dose and dexamethasone 20mg IV. Bortezomib was not given due to thrombocytopenia. Unfortunately, he was not fit to endure the next dose and passed away.