Two Sides of The Same Coin

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• Two Sides of The Same Coin Side 1
  
• Dr.Sujith S.
• MD Resident
• DEPT of
  INTERNAL MEDICINE
• 
  AIMS,KOCHI

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History

• 70 yr old, ex-service man
• Type 2 Diabetes Mellitus x 7 months on medication
• Presented with h/o
• Fever x 1 week
• Generalised body ache x 1 week

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• H/o increased urinary frequency, hesitancy. No
  dysuria
• Admitted at local hospital
• Retention of urine ? Foleys catheter inserted
• Antibiotics ? fever subsided

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• Pain in the left hip joint
• Dull aching pain
• Constant in nature,
• Aggravated with movement
• Radiating to the thigh which caused difficulty in
  movement of hip joint
• No h/o fall
• Not a smoker /does not consume alcohol

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Clinical Examination

• Conscious and oriented, Thin built
• Normal attitude of both LL, avoids movement of
  left hip
• Pallor , Clubbing grade 2
• No icterus/ cyanosis/ lymphadenopathy/ edema
• Temp 98.6 deg F
• PR 80/min, regular, normal character volume ,
  all peripheral
• pulses palpable
• BP 100/70 mm Hg
• RR 22/min SpO2 99 at room air.
• No conjunctival congestion, muscle tenderness,
  skin rash
• Thyroid no swelling

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Systemic Examination

• P/A
• Soft, non tender, no organomegaly
• External genitalia normal
• PR Prostatomegaly
• RS
• B/l Normal vesicular breath sound, No crepts/
  wheeze
• CVS
• S1S2 heard, No murmurs
• NS
• HMF N, CNWNL
• Motor system WNL, Sensory system WNL
• No signs of meningeal irritation, No cerebellar
  signs
• Skull spine normal.
• Fundus - Normal

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Systemic Examination

• Locomotor System
• Limb attitude normal, No limb shortening
• Left hip ROM restricted
• Generalized tenderness over symphysis pubis and
  surrounding areas extending all over the anterior
  aspect of the left thigh
• No distal neurovascular deficit
• Rest of joints normal

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Provisional Diagnosis

• Urinary Tract Infection
• Left hip pain
• ?Reactive/ Septic arthritis
• Anaemia
• Nutritional
• Malignancy

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Investigations

• ESR 80 mm/hr
• Hb 10 gm
• HCT 33.5
• MCV 78 fl
• MCH 24.4 pg
• MCHC 31.4 g/dl
• TC 7200, N-78, L-16
• RBC4 million/uL
• Plt508000Ku/ml

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Investigations

• Total Bilirubin 0.54mgdl
• Direct Bilirubin0.17mg/dl
• SGOT 12.7 IU/L
• SGPT 9.9 IU/L
• ALP 110 IU/L
• T.Protein 8.5 gm/dl
• S.Albumin 3.5 gm/dl
• S.Globulin 5 gm/dl

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• Sr. Urea34.9 mg/dl
• Sr. Creatinine 1.3 mg/dl
• Urine routine examination 10 - 20 pus cells/HPF
• PSA 41.265 ng/ml

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• Peripheral smear
• Normocytic Normochromic anemia with
  thrombocytosis.

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• Blood c/s No growth
• Urine c/s E.Coli Klebsiella? significant
  growth

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• USG Abdomen Pelvis
• Prostatomegaly
• Xray Pelvis

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Lytic Bone Lesion In Elderly

• 1.Metastasis
• 2.Multiple Myeloma

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Lytic Bone lesions

• F Fibrous Dysplasia
• O Osteoblastoma
• G Giant Cell Tumour
• MMetastasis / Myeloma
• A Aneurysmal Bone Cyst
• C Chondroblastoma
• H Hemangioma
• I Infection
• N Non-ossifying Fibroma
• E Eosinophilic Granuloma / Enchondroma
• S Solitary Bone Cyst

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Metastasis from where ? In an Adult

• Adenocarcinomas of
• Breast
• Prostate
• Lung
• Kidney
• Thyroid

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PSA Elevated?

• Prostate cancer
• Prostatic inflammation/infection
• Perineal trauma
• Benign Prostate Hyperplasia

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MRI Pelvis

• Mass lesion involving the left side of prostate
  with large bony lesion involving left side of
  pelvis with soft tissue component

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Provisional Diagnosis

• Ca Prostate with skeletal metastasis

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BUT!!

• Metastasis from prostate vs
• Multiple
  Myeloma bony lesion
• Bone is often the only
  clinically detectable site of metastasis, and the
  resulting tumours tend to be osteoblastic (bone
  forming)

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Xray from Bony metastasis of Prostate cancer
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Skeletal Survey

• Xray Chest-Normal
• Xray Skull-Normal
• Xray Spine-Normal

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Differential Diagnosis

• ?Metastasis
• ?Multiple myeloma

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Myeloma workup

• Sr. Ca 8 mg/dl
• Urine Bence Jones Protein Negative
• Serum Electrophoresis M Band seen

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Causes of M Band

• Multiple Myeloma
• Monoclonal Gammopathy of Undetermined
  Significance
• Waldenstroms macroglobulinemia
• Osteosclerotic myeloma
• POEMs syndrome

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Myeloma workup

• Gammaglobulin
• IgG 2084mg/dl (700-1700mg/dl)
• IgA 268mg/dl (70-350mg/dl)
• IgM 166.96mg/d l(50-300mg/dl)

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Myeloma workup

• Lambda freelite 71.5 mg/L (50mg/L)
• Kappa freelite 76.6mg/L (25mg/L)
• Serum B2 Microglobulin 6.7mg/L (lt2.7mg/L)

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Diagnosis

• Multiple Myeloma
• ?Prostatic mass with raised PSA

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So next ?

• CT guided biopsy of mass and bone lesion

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Histopath pubic bone soft tissue excision biopsy

• Morphological features suggestive of
  plasmacytoma.
• No evidence of mets from ?adenocarcinoma
  prostate
• Immunohistochemical
• CK negative
• CD 138 - positive in all cells
• Lamda 90 of plasma cells show positivity.
• Kappa Upto 30of plasma cells show positivity
• Cystc lesion left pubic bone- Plasmacytoma

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Bone Marrow study

• Bone marrow biopsy from illiac crest
• Cellular marrow with myeloid preponderance with
  interstitial clusters singly scattered plasma
  cells.

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Prostatic Biopsy

• ?Sextant biopsy reveals benign prostatic tissue
  only.
• Patient treated with antibiotics?repeat PSA-
  5ng/ml

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Final Diagnosis

• Multiple Myeloma
• Type 2 Diabetes Mellitus
• BPH with Prostatitis (recovered)

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At present

• Adv next visit regarding initiation of local RT
  to the left pubic ramus(10 cycles)
• Also considering,to initiate on T.Lenalidomide at
  next visit.

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Take Home Message

• PSA in high value?
• Prostate Ca/inflammation
• Prostate Ca-Osteoblastic Mets
• Lytic bone lesions in elderly?
• Mets/Multiple Myeloma

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