|LETTER TO EDITOR
|Year : 2010 | Volume
| Issue : 3 | Page : 351-352
Myelomatous pleural effusion: A diagnostic challenge
KP Malhotra1, V Agrawal1, N Prasad2
1 Department of Pathology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow - 226 014, India
2 Department of Nephrology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow - 226 014, India
|Date of Web Publication||28-Jun-2010|
K P Malhotra
Department of Pathology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow - 226 014
|How to cite this article:|
Malhotra K P, Agrawal V, Prasad N. Myelomatous pleural effusion: A diagnostic challenge. Indian J Cancer 2010;47:351-2
A 50-year-old man presented with fever and oliguria for 5 days and backache for 4 months. Bone marrow aspirate showed 65% atypical plasma cells, and multiple osteolytic lesions were found radiologically. A diagnosis of multiple myeloma with acute-on-chronic renal failure was made. His serum protein was 6.34 gm/dL, albumin 2.7 gm/dL, lactate dehydrogenase (LDH) 158 U/L, b2M 6.1 ΅g/mL, and International Prognostic Index was 3. The patient improved symptomatically with vincristine, adriamycin, and doxorubicin (VAD), local radiotherapy, and hemodialysis. He was re-admitted 1 month later with breathlessness, fever, and bilateral crepitations. Posterior to anterior chest X-ray revealed bilateral pneumonitis. Worsening dyspnea despite adequate antibiotic therapy necessitated a contrast-enhanced computed tomography of thorax, which revealed a collapse consolidation of bilateral lower zones with pleural effusion. Pneumonitis with empyema was considered and pleural fluid aspiration was performed, which was turbid with a high cell count, 4.4 gm% protein, 113.0 mg% sugar, and 122 U/L LDH. Cytology of the centrifuged sediment, stained with May-Grunwald Giemsa and Papanicolaou stains, revealed numerous atypical plasma cells with frequent binucleate forms and mitoses [Figure 1]. Possibility of plasma cells in pleural fluid due to admixture with blood was excluded by a normal total and differential count. Pleural fluid culture was negative. A diagnosis of myelomatous pleural effusion was made and confirmed by monoclonal kappa M band in the gamma region on pleural fluid and serum protein electrophoresis. Thalidomide and pulse steroids were added, but the patient succumbed to the disease after 2 months.
Pleural effusions in myeloma may be a result of sepsis, heart failure secondary to amyloidosis, pulmonary embolism, chronic renal failure, second neoplasm, or pleural myelomatous involvement.  Myelomatous pleural effusions are rare. In contrast, infections are common because of associated hypogammaglobulinemia and chemotherapeutic marrow depression.  In unsuspected cases, a myelomatous effusion may masquerade as empyema. Confusing features include dyspnea, fever, pneumonitis, and pleural exudate with high protein and cell count. Exfoliative cytology remains the most effective diagnostic modality to investigate such cases.
Literature reveals that almost 40% of the cases of myelomatous pleural effusion are due to IgG type, other types being less common.  VAD regime, prednisolone, melphalan, etoposide, cisplatin, stem cell rescue, and pleurodesis have been used in such cases, but have improved the prognosis little.  A single case of partial response to thalidomide and pulse dexamethasone has been reported.  However, our patient showed no relief despite similar therapy.
Myelomatous pleural effusion portends a poor prognosis. A high index of suspicion is required to diagnose patients on chemotherapy with myelomatous effusion, given its rarity, especially when it simulates more common etiologies, such as empyema.
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