Interstitial Pulmonary Fibrosis: An atypical presentation of Multiple Myeloma

Abstract

Introduction: Multiple Myeloma (MM) is a plasma cell dyscrasia, most often seen in old age.[1] Lytic bone lesion, anemia, kidney failure, hypercalcemia and recurrent infection are the most common features. [2,3] Pulmonary parenchyma is an uncommon site of involvement in multiple myeloma. [4] Interstitial lung disease is rarer; only isolated cases have been reported in the literature. [4-7] We report a case of multiple myeloma with rarely seen lung involvement in the form of interstitial pulmonary fibrosis. Case report: A 55/M farmer presented with generalized weakness since three months, low backache since two months and breathlessness on exertion since eight days. He had pallor and icterus but no clubbing, cyanosis or lymphadenopathy. He had bilateral scattered crepitations and tender anterior superior iliac spine and was investigated on OPD basis as well as also in the hospital during this time. However patient had atypical presentation in form of anemia, USG abdomen showed hepatomegaly and renal parenchymal disease. X ray lumbosacral spine and X ray skull revealed osteopenia and multiple lytic lesions. CXR-PA view showed reticulonodular pattern all over the lung fields. Anemia, renal involvement and lytic lesions gave rise to suspicion of multiple myeloma. Bone marrow examination showed 50% clonal plasma cells in lymphoid series and obscuration of all the three series by plasma cells. Serum electrophoresis showed elevated beta-2-microglobulin level to 3.7gm/dl (N-1.3to1.5 gm/dl). Diagnosis of MM was made based on the above findings.. On further investigation, urine was found to be positive for Bence-Jones proteins and M band. The findings of crepitations in chest associated with reticulonodular pattern of fibrosis in both lung fields on chest X-Ray PA view, suggestive of interstitial pulmonary fibrosis and hepatomegaly with icterus were unusual findings in a case of MM. Conclusion: Pulmonary parenchyma involvement is rare in multiple myeloma. In the few cases described, it is usually secondary to an infectious process or primary bone involvement. [8] Symptomatic liver disease is extremely rare although jaundice is occasionally seen.We are discussing this case because it showed pulmonary symptoms as the primary complaint at presentation, with simultaneous involvement of kidneys and liver.