A 65 year-old male, smoker and occasional alcoholic with a history of left pneumothorax and ischemic heart disease was admitted to our department. The patient presented weakness, significant weight loss, progressive shortness of breath associated to chronic cough and with ongoing hemoptysis over 5 months. Physical examination then found a pale patient with an increasing pulse rate of 120/min and fluctuating oxygen saturation between 91% and 97% on room air. Pulmonary examination revealed dullness and decreased breath sounds at the left hemithorax. His chest radiograph showed two dense, heterogeneous and rounded opacities in the left lung without any visible osteolytic lesions [Fig. 1].
First Computerized tomography (CT) of the thorax was performed revealing a peripheral heterogeneous mass (51.3 mm x 63.7mm x 42 mm) involving the lower left lobe in contact with chest wall without focal erosion associated to subpleural nodule with moderate loculated left pleural effusion. A second thoracic CT scan preformed within 3 months showed a progression of the lesion (119 mm x 87 mm x 118mm) associated to left pleural masses, nodules and controlateral nodule in the right Fowler. Centrilobular and panlobular emphysema with infracentimetric mediastinal lymph nodes were also seen [Fig. 2].
Pleural fluid was hemorrhagic, exudative, lymphocyte predominant. Smear and culture for mycobacterium tuberculosis were negative. Pleural fluid cytology did not reveal any malignant cells. Laboratory blood investigation showed he had severe yet tolerated anemia with hemoglobin at 7.5 g/dl, total leukocyte count was 8760 cell/mm3, platelets were 364 000 cells/mm3, total serum proteins were 81 mg/dl with serum albumin at 2.4 g/dl. Renal function was normal and no hypercalcemia was found. Serum protein electrophoresis was done and did not reveal any abnormalities. Urinary protein electrophoresis showed a band at the level of total Kappa light chains but without any correspondence with the free light chains.
On bronchoscopic exploration, there was a small bleed coming from the culminal bronchus where we found a flat, smooth and blackish endobronchial formation. We also identified an extra luminal compression of the left Nelson bronchus with no endobronchial growth. A biopsy of the suspected formation was done but the results were inconclusive. Therefore, a CT-guided transparietal lung biopsy was performed and revealed unusual mature plasma cell clusters suggestive of plasmacytoma. We completed our investigations with a bone marrow biopsy and the results showed a rich marrow of many megakaryocytes and 12% of plasma cells. No blasts or extra hematopoietic cells have been identified [Fig. 3].
The patient's skull X-Ray also revealed multiple lytic lesions indicating a MM [Fig. 4].
The diagnosis of MM with lung plasmacytoma was then made on the basis of plasma cell infiltration of the bone marrow, lytic bone lesions, and the presence of dystrophic plasma cells in the lung mass. The patient was transferred to the Hematology department for chemotherapy but months later he was unfortunately reported out of sight.