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Pulmonary Manifestations in a Case of Multiple Myeloma
Pulmonary Manifestations in a Case of Multiple Myeloma jORMA PATIALA, M.D., F.C.C.P., AND LOUIS PERRET, M.D.
Helsinki, Finland
W
E LL
DEMARCATED,
TUMOR - LIKE
chest x-ray findings in myeloma are rather uncommon, though a number of such cases have been reported during the last decade. The following case of myeloma presents unusual changes in the lungs. CASE REPORT
A 72-year-old woman, retired athletic instructor, with the chief complaint of shortness of breath, tiredness and vague pains in the back, entered the Department of Pulmonary Diseases, University of Helsinki. A week earlier, a chest roentgenogram had been taken because of a sudden onset of fever, which disappeared some days later. The chest x-ray film showed a large, tumorlike mass in the lower lobe of right lung, covering the apical and lateral segment and in the left lung a laterally situated density, corresponding to the area of the posterior and lateral basal segment (Figs. 1 and 2). Tomograms showed a slight erosion of the sixth and seventh ribs of the right lung and roentgenograms of the bones a marked diffuse osteoporosis. In the skull, two quite small, indistinct punched-out areas could be seen. A small, rounded, tumor-like density, apparently originating from the posterior wall of the trachea at the level of the third thoracic vertebra could also be seen in the lateral tomograms (Fig. 3) . Many years ago she had been treated in a hospital for fracture of the upper part of the
FIGURE
shaft of the femur , but an evident connection with the current disease cannot be established. The chest finding was suggestive of a bronchogenic carcinoma of the right lung with metastases in the left lung and in the trachea. However, her general condition was fairly good and so another explanation of the disease was sought. Needle aspiration from the tumor of the right lung showed only blood cells and nonspecific "inflammatory" cells, but no neoplastic cells. An
I
117
FIG URE
2
FIG URE
3
PATIALA AND PERRET
118
electrophoretic fractionation gave a valuable clue to the diagnosis: The gamma globulin component was increased to 48 per cent, the total amount of plasma proteins also being increased to 9 gm. per 100 ml, of plasma. She had a slight bacterial infection of the urinary passages with small amounts of protein in the urine. A typical Bence-Jones proteinuria could not be demonstrated. The electrophoretic pattern was in a striking manner confirmed by an imuno-electrophoretic analysis where a typical gamma-M-component was found. The sternal puncture showed a great number of typical "myeloma cells." DISCUSSION
As pointed out by Carpenter et al./ significant abnormalities of the serum proteins can be useful aids in the differential diagnosis of chest diseases. In this case, the simple method of paper electrophoresis gave a considerable rise in the gamma globulin component, and this finding together with a hyperproteinemia pointed to the diagnosis of multiple myeloma. The latter
Diseases of the Chest
was confirmed by immuno-electrophoresis and sternal puncture. Thus, the serum protein analysis must always be kept in mind as chest clinics are receiving an increasing number of obscure cases with lungs "as a mirror of systemic disease." ACKNOWLEDGMENT: The authors wish to express their gratitude to Professor Guido Totterman and Dr. Nils-Erik Saris for their cooperation in studying this patient.
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3
4
5
REFERENCES AUDA, L.: "Multiple Myeloma," Acta Radiologica, (Stockholm), 33:515, 1950. CARPENTER, C. M., HEISKELL, C. L., WEIMER, H. E., FUKUDA, M., YACHI, A., AND WADA, T.: "Serum Protein Abnormalities in Neoplastic and Non-Neoplastic Disease of the Lung," Dis. Chest, 40: 245, 1961. ROZSA, S., AND FRIEMAN, H.: "Extramedullary Plasmocytoma of the Lung," Am. /. Roentgen., 70: 982, 1953. RUBIN, E. H.: The Lung as a Mirror of Systemic Disease, Charles C Thomas, Springfield, 1956. WHITE, S., AND TILLINGHAST, A.: "Multiple Myeloma. An Analysis of Twenty-one Proved Cases," Am. t. Roentgen., 63:851, 1950.
LATE RESULTS OF 1000 MITRAL COMMISSUROTOMIES The authors report on the late results of 1000 mitral commissurotomies. Eight years have passed since the performance of the first surgical Intervention. The operative results are characterized In the first place by Improvement in the subjective symptoms of the respiratory difficulties and In productivity. and in the second place by the changes observed In physical signs. auscultatory findings, ECG, and x-ray findings. They discuss the significance of the formation of auricular thrombus. embollzatlon In the systemic circulation, auricular
fibrillation, decompensation In the systemic circulation. calcification of the valves, mitral regurgitation. and further of the postoperative compllcatlons In the development of the operative results. The postoperative result was good In 58 per cent, moderate In 25 per cent, and In 13 per cent there was no Improvement at all or the disease progressed further. The operative mortallty was 3.6 per cent. I., KUDASZ, J., LITIMAN, I., AND SZANTO, A.: "Late Results of 1000 Mitral Commissurotomies," Cor II Vasa. 3:48, 1961.
KUNOS,
PHYSIOLOGIC CHANGES AFTER CLOSURE OF VENTRICUL..\ R SEPTAL DEFECTS Pre- and postoperative physiologic data are presented for 57 patients who have had successful closure of ventricular septal defects. These data demonstrate that the fall In pulmonary artery pressure after surgery Is In direct proportion to the decrease In pulmonary flow affected by surgical closure of the ventricular septal defect. There Is no evidence to Indicate any regression toward normal of pulmonary vascular pathology In the first year or two after closure of the defect. The patients with
the best results-those with the lowest residual postoperative pulmonary artery pressures-are those with the smallest elevation in calculated total pulmonary resistance before surgery. A near-normal total pulmonary resistance may exist at any age. but Is present most commonly in younger patients with ventricular septal defect. PAUL, JR., ANDERSON, R. C., MEYNE, N., AND LJLLEHEI, C. W.: "Physiologic Changes after Closure of Ventricular Septal Defects," t. Lanett, 81 :497. 1961.
ADAMS,
Helsinki, Finland
W
E LL
DEMARCATED,
TUMOR - LIKE
chest x-ray findings in myeloma are rather uncommon, though a number of such cases have been reported during the last decade. The following case of myeloma presents unusual changes in the lungs. CASE REPORT
A 72-year-old woman, retired athletic instructor, with the chief complaint of shortness of breath, tiredness and vague pains in the back, entered the Department of Pulmonary Diseases, University of Helsinki. A week earlier, a chest roentgenogram had been taken because of a sudden onset of fever, which disappeared some days later. The chest x-ray film showed a large, tumorlike mass in the lower lobe of right lung, covering the apical and lateral segment and in the left lung a laterally situated density, corresponding to the area of the posterior and lateral basal segment (Figs. 1 and 2). Tomograms showed a slight erosion of the sixth and seventh ribs of the right lung and roentgenograms of the bones a marked diffuse osteoporosis. In the skull, two quite small, indistinct punched-out areas could be seen. A small, rounded, tumor-like density, apparently originating from the posterior wall of the trachea at the level of the third thoracic vertebra could also be seen in the lateral tomograms (Fig. 3) . Many years ago she had been treated in a hospital for fracture of the upper part of the
FIGURE
shaft of the femur , but an evident connection with the current disease cannot be established. The chest finding was suggestive of a bronchogenic carcinoma of the right lung with metastases in the left lung and in the trachea. However, her general condition was fairly good and so another explanation of the disease was sought. Needle aspiration from the tumor of the right lung showed only blood cells and nonspecific "inflammatory" cells, but no neoplastic cells. An
I
117
FIG URE
2
FIG URE
3
PATIALA AND PERRET
118
electrophoretic fractionation gave a valuable clue to the diagnosis: The gamma globulin component was increased to 48 per cent, the total amount of plasma proteins also being increased to 9 gm. per 100 ml, of plasma. She had a slight bacterial infection of the urinary passages with small amounts of protein in the urine. A typical Bence-Jones proteinuria could not be demonstrated. The electrophoretic pattern was in a striking manner confirmed by an imuno-electrophoretic analysis where a typical gamma-M-component was found. The sternal puncture showed a great number of typical "myeloma cells." DISCUSSION
As pointed out by Carpenter et al./ significant abnormalities of the serum proteins can be useful aids in the differential diagnosis of chest diseases. In this case, the simple method of paper electrophoresis gave a considerable rise in the gamma globulin component, and this finding together with a hyperproteinemia pointed to the diagnosis of multiple myeloma. The latter
Diseases of the Chest
was confirmed by immuno-electrophoresis and sternal puncture. Thus, the serum protein analysis must always be kept in mind as chest clinics are receiving an increasing number of obscure cases with lungs "as a mirror of systemic disease." ACKNOWLEDGMENT: The authors wish to express their gratitude to Professor Guido Totterman and Dr. Nils-Erik Saris for their cooperation in studying this patient.
2
3
4
5
REFERENCES AUDA, L.: "Multiple Myeloma," Acta Radiologica, (Stockholm), 33:515, 1950. CARPENTER, C. M., HEISKELL, C. L., WEIMER, H. E., FUKUDA, M., YACHI, A., AND WADA, T.: "Serum Protein Abnormalities in Neoplastic and Non-Neoplastic Disease of the Lung," Dis. Chest, 40: 245, 1961. ROZSA, S., AND FRIEMAN, H.: "Extramedullary Plasmocytoma of the Lung," Am. /. Roentgen., 70: 982, 1953. RUBIN, E. H.: The Lung as a Mirror of Systemic Disease, Charles C Thomas, Springfield, 1956. WHITE, S., AND TILLINGHAST, A.: "Multiple Myeloma. An Analysis of Twenty-one Proved Cases," Am. t. Roentgen., 63:851, 1950.
LATE RESULTS OF 1000 MITRAL COMMISSUROTOMIES The authors report on the late results of 1000 mitral commissurotomies. Eight years have passed since the performance of the first surgical Intervention. The operative results are characterized In the first place by Improvement in the subjective symptoms of the respiratory difficulties and In productivity. and in the second place by the changes observed In physical signs. auscultatory findings, ECG, and x-ray findings. They discuss the significance of the formation of auricular thrombus. embollzatlon In the systemic circulation, auricular
fibrillation, decompensation In the systemic circulation. calcification of the valves, mitral regurgitation. and further of the postoperative compllcatlons In the development of the operative results. The postoperative result was good In 58 per cent, moderate In 25 per cent, and In 13 per cent there was no Improvement at all or the disease progressed further. The operative mortallty was 3.6 per cent. I., KUDASZ, J., LITIMAN, I., AND SZANTO, A.: "Late Results of 1000 Mitral Commissurotomies," Cor II Vasa. 3:48, 1961.
KUNOS,
PHYSIOLOGIC CHANGES AFTER CLOSURE OF VENTRICUL..\ R SEPTAL DEFECTS Pre- and postoperative physiologic data are presented for 57 patients who have had successful closure of ventricular septal defects. These data demonstrate that the fall In pulmonary artery pressure after surgery Is In direct proportion to the decrease In pulmonary flow affected by surgical closure of the ventricular septal defect. There Is no evidence to Indicate any regression toward normal of pulmonary vascular pathology In the first year or two after closure of the defect. The patients with
the best results-those with the lowest residual postoperative pulmonary artery pressures-are those with the smallest elevation in calculated total pulmonary resistance before surgery. A near-normal total pulmonary resistance may exist at any age. but Is present most commonly in younger patients with ventricular septal defect. PAUL, JR., ANDERSON, R. C., MEYNE, N., AND LJLLEHEI, C. W.: "Physiologic Changes after Closure of Ventricular Septal Defects," t. Lanett, 81 :497. 1961.
ADAMS,