images in haematology
Bilateral renal infiltration as the initial presentation of multiple myeloma
A 66-year-old woman with no previous history of kidney disease presented with an elevated serum creatinine [1326 lmol/l, normal range (NR) 3536–6188] detected at a health checkup. Physical examination showed neither lymphadenopathy nor hepatosplenomegaly. Her blood count showed a haemoglobin concentration of 103 g/l, white blood cell count of 39 9 109/l with no abnormal cells and a platelet count of 297 9 109/l. The total serum protein concentration was 118 g/l (NR 67–83), and calcium was 238 mmol/l (NR 217–257). The levels of immunoglobulin (Ig) G, IgA and IgM were 122 (NR 86–164), 572 (NR 10–43) and 076 g/l (NR 035–22) respectively. Immunoelectrophoresis of serum proteins showed the presence of an IgAj paraprotein. Urine was negative for Bence–Jones protein. Whole body radiology and magnetic resonance imaging (MRI) showed no lytic bone lesions. Bone marrow aspirate and biopsy were performed, showing 5% plasma cells with j light chain restriction. 18F-fluorodeoxyglucose positron emission tomography (18FDG-PET) showed diffuse uptake in both kidneys (left) and a renal biopsy was performed. Histology showed a core of renal parenchyma with three glomeruli. There was no hypercellularity, necrosis or crescent formation and Congo red staining was negative. A dense First published online 11 July 2014 doi: 10.1111/bjh.13022
interstitial infiltrate composed of atypical plasma cells that were positive for CD38 (upper right), CD56 and cytoplasmic j-chain (lower right) was detected. Because of the gradual progression of anaemia and hypercalcaemia, a second bone marrow aspiration was performed 3 months after the PET scan. Plasma cells had increased to 112% and showed an identical phenotype to those of the kidney specimen. A diagnosis of multiple myeloma was made. The 18FDG-PET scan was a conclusive diagnostic factor in the present case, showing a unique pattern of bilateral renal involvement. Myelomatous infiltration of the kidney is rare, although elevation of serum creatinine is found at presentation in 50% of patients. The use of 18FDG-PET during the diagnostic work-up of patients with myeloma can be of value in identifying renal infiltration as the cause of renal dysfunction. Yasushi Kubota1,2, Miwako Matsuzaki3 and Shinya Kimura1 1
Division of Haematology, Respiratory Medicine and Oncology, Depart-
ment of Internal Medicine, Faculty of Medicine, Saga University, 2 Department of Transfusion Medicine, Saga University Hospital, Saga, and 3Department of Internal Medicine, Kozenkai Maeda Hospital,
Imari, Japan. E-mail: [email protected]
ª 2014 John Wiley & Sons Ltd British Journal of Haematology, 2014, 167, 2
Bilateral renal infiltration as the initial presentation of multiple myeloma
A 66-year-old woman with no previous history of kidney disease presented with an elevated serum creatinine [1326 lmol/l, normal range (NR) 3536–6188] detected at a health checkup. Physical examination showed neither lymphadenopathy nor hepatosplenomegaly. Her blood count showed a haemoglobin concentration of 103 g/l, white blood cell count of 39 9 109/l with no abnormal cells and a platelet count of 297 9 109/l. The total serum protein concentration was 118 g/l (NR 67–83), and calcium was 238 mmol/l (NR 217–257). The levels of immunoglobulin (Ig) G, IgA and IgM were 122 (NR 86–164), 572 (NR 10–43) and 076 g/l (NR 035–22) respectively. Immunoelectrophoresis of serum proteins showed the presence of an IgAj paraprotein. Urine was negative for Bence–Jones protein. Whole body radiology and magnetic resonance imaging (MRI) showed no lytic bone lesions. Bone marrow aspirate and biopsy were performed, showing 5% plasma cells with j light chain restriction. 18F-fluorodeoxyglucose positron emission tomography (18FDG-PET) showed diffuse uptake in both kidneys (left) and a renal biopsy was performed. Histology showed a core of renal parenchyma with three glomeruli. There was no hypercellularity, necrosis or crescent formation and Congo red staining was negative. A dense First published online 11 July 2014 doi: 10.1111/bjh.13022
interstitial infiltrate composed of atypical plasma cells that were positive for CD38 (upper right), CD56 and cytoplasmic j-chain (lower right) was detected. Because of the gradual progression of anaemia and hypercalcaemia, a second bone marrow aspiration was performed 3 months after the PET scan. Plasma cells had increased to 112% and showed an identical phenotype to those of the kidney specimen. A diagnosis of multiple myeloma was made. The 18FDG-PET scan was a conclusive diagnostic factor in the present case, showing a unique pattern of bilateral renal involvement. Myelomatous infiltration of the kidney is rare, although elevation of serum creatinine is found at presentation in 50% of patients. The use of 18FDG-PET during the diagnostic work-up of patients with myeloma can be of value in identifying renal infiltration as the cause of renal dysfunction. Yasushi Kubota1,2, Miwako Matsuzaki3 and Shinya Kimura1 1
Division of Haematology, Respiratory Medicine and Oncology, Depart-
ment of Internal Medicine, Faculty of Medicine, Saga University, 2 Department of Transfusion Medicine, Saga University Hospital, Saga, and 3Department of Internal Medicine, Kozenkai Maeda Hospital,
Imari, Japan. E-mail: [email protected]
ª 2014 John Wiley & Sons Ltd British Journal of Haematology, 2014, 167, 2
