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Case Reports and Images in Oncology

 
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Case Report
 
Multiple myeloma revealed by a monoarthritis: A case report
Aissam El Maataoui1, Nabiha Kamal2
1Ibn Zohr University, Faculty of medecine and pharmacy, Agadir.
2Hassan II University, Faculty of medecine and pharmacy, Casablanca.

Article ID: 100009Z10AM2015
doi:10.5348/Z10-2015-9-CR-9

Address correspondence to:
Aissam El Maataoui
Biochemistry department at the Ibn Rochd hospital
Casablanca
Morocco

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How to cite this article:
El Maataoui A, Kamal N. Multiple myeloma revealed by a monoarthritis: A case report. J Case Rep Images Oncology 2015;1:36–38.


Abstract
Introduction: Multiple myeloma (MM) is defined by the presence of monoclonal protein in the urine and/or serum, and bone-marrow plasma cells greater than 10%. Musculoskeletal manifestations of this disorder are rare.
Case Report: We report a case of an 80-year-old female patient presenting with monoarthritis and joint swelling, detailed investigations revealed that she was suffering from multiple myeloma in which monoarthritis was a musculoskeletal complication of the disease.
Conclusion: We report a case of a patient presenting with monoarthritis and joint swelling diagnosed with multiple myeloma.

Keywords: Multiple myeloma, Monoarthritis, Malignancy, Musculoskeletal manifestation


Introduction

Multiple myeloma (MM) is characterized by a neoplastic proliferation of plasma cells associated, in more than 95% of cases, with the production of a single class of immunoglobulins known as a monoclonal protein, which can be either its subclass or its light chain in the serum or urine. Multiple myeloma can occasionally manifest with joint disease. We report an unusual case of MM initially manifested by monoarthritis and joint swelling.


Case Report

An 80-year-old female patient with a history of hypertension referred to the rheumatology department with a 20-day history of progressive disabling monoarthralgia and knee swelling. Hypertension was diagnosed 10 years ago. There were no other chronic comorbidities such as diabetes mellitus, renal disease, recurrent urinary tract infections, chronic alcoholism, or pre-existing joint damage such as chronic arthritis and prosthetic joints.

At the admission the patient presented with a 10-day history of general malaise and fever. She also gave a five-day history of a painful and swollen right knee unrelated to trauma. Acute monoarthritis in adults can have many causes, but crystals, trauma, and infection are the most common. A diagnostic aspirate of the knee joint yielded minimal clear synovial fluid. Investigations showed normochromic normocytic anemia with a hemoglobin of 54 g/l, white cell count of 13.11×109/l (4.0–10.0×109/l) and platelets of 278×109/l and a grossly raised erythrocyte sedimentation rate (>140 mm/hr). She was hypercalcemic (corrected calcium 132 mg/l), phosphate 65.5 mg/l, alkaline phosphatase 46 U/l (40–150 U/L) with normal liver function (ALT 7 U/l, AST 8 U/l, normal bilirubin). Significant renal disease was evident urea 1.36 g/l (0.13–0.43 g/l), creatinine 20.8 mg/l (6–13 g/l), uric acid 111.8 mg/l (26–60 mg/l), proteinemia 97 g/l (60–80 g/l) and β2-microglobulinemia 59.29 mg/l (0.5–2.4 g/l). Here albumin was 19 g/l (40–50 g/l), Fibrinogen 4.30 g/l (2.0–4.0 g/l) and C-reactive protein was 149.4 mg/l (0.0–5.0 mg/l). Acute monoarthritis was caused by a crystal deposition of uric acid.

Immunoturbidimetric analysis showed that monoclonal hypergammaglobulinemia was due to the increase of IgG with the value of 28.96 g/l (8–16 g/l). Serum protein electrophoresis revealed a big paraprotein band (98 g/l) (Figure 1). Serum immunofixation showed the presence of an IgG-Lambda gammopathy (Figure 2). Urine immunofixation showed also the presence of an IgG-Lambda gammopathy (Figure 2). A bone marrow smear revealed that 37% of plasma cells were dystrophic. Bone X-ray of the skull showed multiple lytic lesions. Multiple myeloma was diagnosed by examining of bone marrow aspiration and biopsy showing the existence of plasma cells infiltration and plasmacytosis with 32% malignant plasma cells. Thus a diagnosis of MM stage III of the International Staging System was made.


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Figure 1: Serum protein electrophoresis.



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Figure 2: Serum and urine immunofixation.



Discussion

Here we report a case of an 80-year-old female patient presenting with monoarthritis and joint swelling, detailed investigations revealed that she was suffering from MM in which monoarthritis was a musculoskeletal complication of the disease. On review of the literature, a few case reports have described articular presentations associated with MM. MM is defined by the presence of monoclonal protein in the urine and/or serum, and bone-marrow plasma cells greater than 10%. Symptomatic disease is characterized by evidence of end-organ damage caused by plasma cell proliferation, or CRAB features: C: hypercalcaemia (>11.5 mg/dL (2.65 mmol/L]); R: renal failure (serum creatinine >2 mg/dL [1.73 mmol/L]); A: anemia (hemoglobin <10 g/dL [12.5 mmol/L] or >2 g/dL [1.25 mmol/L] below the lower limit of normal); and B: bone disease (lytic lesions, severe osteopenia or pathologic fractures) [1].

Also, investigations revealed acute kidney injury associated with MM. The most common cause of severe renal failure in patients with MM is a tubulointerstitial pathology that results from the very high circulating concentrations of monoclonal immunoglobulin free light chains. These endogenous proteins can result in isolated proximal tubule cell cytotoxicity, tubulointerstitial nephritis and cast nephropathy [2]. The increase in uric acid level in this case may be a consequence of decreased clearance caused by the impairment in glomerular filtration rate, or it may reflect local tissue hypoxia or increased cell breakdown associated with renal disease [3]. Hyperphosphatemia is linked to renal failure. Thus, loss of phosphorus homeostasis due to excretion failure in chronic kidney disease and the effects of disordered bone remodelling results in hyperphosphatemia [4]. The beta-2 microglobulin is elevated in proportion to tumor mass and is associated with the renal failure in this case.

Monoarthritis and joint swelling were the initial presentation of MM in this case report. Indeed, the mechanism underlying joint involvement in MM could be either due to both septic arthritis and gouty arthritis [5]. In this case, serum uric acid level was very out of range, but no crystals were found on the synovial fluid examination, probably this monoarthritis is a gouty arthritis.

Other pathophysiological mechanisms, underlying joint involvement in MM are erosive arthritis due to local synovial precipitation of cryoprecipitable paraproteins [6] or immunoglobulin crystals [7], that activate the inflammatory response. Secondly, a carpal tunnel syndrome may develop from intrasynovial deposition of amyloid protein or immunoglobulins [8].


Conclusion

We report a case of an 80-year-old female patient presenting with monoarthritis and joint swelling, detailed investigations revealed that she was suffering from multiple myeloma in which monoarthritis was a musculoskeletal complication of the disease. On review of the literature, a few case reports have described particular presentations associated with multiple myeloma.


References
  1. Gay F, Palumbo A. Management of older patients with multiple myeloma. Blood Rev 2011 Mar;25(2):65–73.   [CrossRef]   [Pubmed]    Back to citation no. 1
  2. Hutchison CA, Batuman V, Behrens J, et al. The pathogenesis and diagnosis of acute kidney injury in multiple myeloma. Nat Rev Nephrol 2011 Nov 1;8(1):43–51.   [CrossRef]   [Pubmed]    Back to citation no. 2
  3. Kang DH, Nakagawa T.Uric acid and chronic renal disease: possible implication of hyperuricemia on progression of renal disease. Semin Nephrol 2005 Jan;25(1):43–9.   [CrossRef]   [Pubmed]    Back to citation no. 3
  4. Hruska KA, Mathew S, Lund R, Qiu P, Pratt R. Hyperphosphatemia of chronic kidney disease. Kidney Int 2008 Jul;74(2):148–57.   [CrossRef]   [Pubmed]    Back to citation no. 4
  5. Roux S, Fermand JP, Brechignac S, Mariette X, Kahn MF, Brouet JC. Tumoral joint involvement in multiple myeloma and Waldenström's macroglobulinemia--report of 4 cases. J Rheumatol 1996 Dec;23(12):2175–8.   [Pubmed]    Back to citation no. 5
  6. Jorgensen C, Guerin B, Ferrazzi V, Bologna C, Sany J. Arthritis associated with monoclonal gammapathy: clinical characteristics. Br J Rheumatol 1996 Mar;35(3):241–3   [CrossRef]   [Pubmed]    Back to citation no. 6
  7. Langlands DR, Dawkins RL, Matz LR, et al. Arthritis associated with a crystallizing cryoprecipitable IgG paraprotein. Am J Med 1980 Mar;68(3):461–5.   [CrossRef]   [Pubmed]    Back to citation no. 7
  8. Wiernik PH. Amyloid joint disease. Medicine (Baltimore) 1972 Nov;51(6):465–79.   [CrossRef]   [Pubmed]    Back to citation no. 8

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Author Contributions
Aissam El Maataoui – Substantial contributions to conception and design, Acquisition of data, Analysis and interpretation of data, Drafting the article, Revising it critically for important intellectual content, Final approval of the version to be published
Nabiha Kamal – Analysis and interpretation of data, Revising it critically for important intellectual content, Final approval of the version to be published
Guarantor of submission
The corresponding author is the guarantor of submission.
Source of support
None
Conflict of interest
Authors declare no conflict of interest.
Copyright
© 2015 Aissam El Maataoui et al. This article is distributed under the terms of Creative Commons Attribution License which permits unrestricted use, distribution and reproduction in any medium provided the original author(s) and original publisher are properly credited. Please see the copyright policy on the journal website for more information.



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