Unusual and extremely rare presentation of multiple myeloma with extra-medullary plasmacytomas: a case report.

A 59-year-old African American male presented with a 1-month history of worsening back pain, radiating down legs bilaterally, with numbness and tingling in anterior thighs, episodic weakness in left leg, but no bowel or bladder incontinence. Data included LS x-ray: large osteophytes at all levels; MRI thoracic and lumbar spine: multiple signal abnormalities in T2, T4, T9, T12 and S1 suggestive of a diffuse bone marrow process; bone marrow aspirate and biopsy: 15% plasma cells; mild anemia, normal serum Ca; bone survey: unrevealing; SPEP: M-spike in the gamma region, IgA lambda light chain on immunofixation; quantitative immunoglobulins: IgA 1890 mg/dL, with lower than normal serum IgG and IgM levels; UPEP: not performed secondary to insufficient amount of urine protein; ESR: 62; BMP, LFTs normal; *-2 microglobulin: 1.3 mg/L. He was treated with melphalan and prednisone given for 4 days in cycles repeated every 4 to 6 weeks as recovery of cell counts permitted. Treatment was initially well tolerated with good response. After three cycles, he developed multiple, rapidly enlarging subcutaneous nodules, distributed on arms, neck, scalp and chest. Some of these were greater than 2 inches in diameter. IgA level was increased to 2484 mg/dL and *-2 microglobulin was 2.4 mg/L. These multiple lesions were biopsy proven plasmacytomas. Thalidomide was started at 200 mg po qhs, and local radiation was given only to the biggest lesions. This was followed by combination systemic chemotherapy VAD while thalidomide was continued. A dramatic resolution of skin lesions and normalization of IgA were observed within the first six weeks. The patient remains in complete remission after 4 cycles, awaiting autologous stem cell support. This rare case highlights the importance of systemic chemotherapy in multiple extraosseous plasmacytomas and suggests that thalidomide may add to the usual response observed with chemo/radiation.

Ganesh D. Kini, MD, PhD, and Jose L. Mendoza, MD, University of Virginia, Roanoke-Salem Program in Internal Medicine, Roanoke, VA. Department of Hematology/Oncology, The VA Medical Center, Salem, VA.