The patient was a 33-year-old man admitted to the rheumatology ward with severe low back pain commencing in the past 3 months. The pain was mainly in the lumbar and sacroiliac vertebra and sternum, and movement and rotation exacerbated it and woke him up at night. He mentioned 12 kg weight loss. He had a history of non-pasteurized dairy consumption in the past 3 months and no history of trauma, nausea, blurred vision, or fever. Also, no smoking history was mentioned, and he had no family history of hematologic diseases. Different types of NSAIDs were prescribed for back pain, which over time proved ineffective. In physical examination, tenderness was evident in the sternum, right lower ribs, lumbar, and right sacroiliac joint. Also, a decrease in flexion and lateral bending was detected, deep tendon reflexes and muscle forces were normal, and the Babinski test was negative in both limbs.
His young age and chief complaints led to the diagnosis of brucellosis, the endemic disease of the region. Other differential diagnoses were propounded, such as tuberculosis, ankylosing spondylitis, and malignancy. The list of laboratory results is shown in the Table 1.
Abdominopelvic ultrasonography showed mild spleen enlargement (splenic span of 136 mm). Cranial radiography showed several lytic lesions of different sizes, accompanied by a slight increase in the cranial bone thickness. Thoracolumbar magnetic resonance imaging (MRI) study showed multiple abnormal lesions in vertebral bodies of the thoracolumbar spinal column. In addition, in the pelvis and thoracolumbar MRI, diffused abnormal bone marrow signal intensity was noted in favor of MM (Figure 1).
Serum protein electrophoresis (SPEP) showed a peak in beta-1. The urinary protein electrophoresis (UPEP) showed a significant increase in free light chains, IgG/IgA, mixed tubular and glomerular, and Bence Jones proteinuria. Bone marrow aspiration and biopsy (BMA and BMB) were performed for him. Histopathologic examination showed that more than 80% of all nucleated cells were plasma cells or plasmablasts (Figure 2).
Immunophenotyping of BMA by flow cytometry shows a predominantly abnormal plasma cell population that is positive for CD38, CD138, and CD56 and negative for CD19. In the cytogenetic study, 44,X,-Y,der(1)del(1)(p13,3p22)del(1)(p31,3p33),del(2)(q13),der(3)t(1;3)(q12;q27),del(6)(q13 q27),-8,del(12)(p11,2),-13,-18,+mar x 2[8]/45,sl,+mar[10]/44,sl,del(1)(q12q25), add(16)(q13)[2] was present.
In Fluorescence in situ Hybridization (FISH) report, he had 74% amplification of 1q21, 89% deletion of 6q21, 97% deletion of 13q14.3, 81% positive IGH break, and 81% t(4;14) (p16;q32) FGFR3/IGH. Therefore, the final diagnosis of high-risk MM was made based on the available findings.
Treatment started with a VRD regimen which includes bortezomib 1.3 mg/m2 (days 1, 4, 8, 11, 22, 25, 29, 32), lenalidomide 25 mg, and dexamethasone 40 mg. His back pain decreased after the fourth session of treatment. In the BMA and BMB that were taken on the last session of the fourth cycle, plasma cell counts decreased to 3%, contributing to complete remission. Regarding the adequate response, he was selected as a candidate for autologous bone marrow transplantation.
2 days after the first session of the fifth cycle, he was admitted to the emergency department with an abrupt fever of 40 C, anosmia, anorexia, weakness, Mild dyspnea, and reduction in oxygen saturation (91% without oxygen). Laboratory studies and spiral chest computed tomography (CT) were requested. Multiple peripheral patchy ground-glass opacities were unveiled in the CT scan (Figure 3). The coexistence of positive reverse transcription-polymerase chain reaction (RT-PCR) made a definite diagnosis of COVID-19 infection. He was admitted to the infectious disease ward for isolation and treatment, and his chemotherapy session was postponed. After 2 days, the fever subsided. During treatment, he showed no sign of dyspnea or respiratory distress, and oxygen saturation was above 94%. He was discharged from the hospital without any complications. Approximately 20 days after discharge, a vague pain started in his feet and back. The pain intensity increased, and on the day of negative RT-PCR, he was admitted with excruciating pain in the lower limbs and his back, which was resistant to regular analgesic drugs. SPEP, which became normal before COVID-19, showed a peak in beta-1, and MM relapse diagnosis was confirmed. Afterward, he received different treatments such as a repeat VRD regimen, Bortezomib/Cyclophosphamide/Dexamethasone (VCD), Pegylated liposomal Doxorubicin/Bortezomib and Bendamustin containing regimen but non showed any acceptable results.