A 71–year–old man with hypothyroidism presented with atypical left–sided pain to the emergency room. The patient developed acute left–sided pain about 2 months prior to presentation to ER. The pain started in the lower extremity and advanced to his thigh, abdomen, arm, and neck. He described the pain as dull in nature. The pain had progressed to the point that he had difficulty ambulating and sleeping due to pain. He had seen his primary care physician and has had an negative work–up at an outside hospital. In 3 weeks prior to presenting to our hospital, he had lost his taste, appetite, and lost 7 pounds. Other review of systems were negative. Repeat skeletal xrays were negative except for moderate degenerative disc changes in L–spine and mild to moderate degenerative disc changes in C–spine. There were slightly narrowed neural foramina in the lower cervical region. Patient’s laboratory values were positive for hemoglobin of 12.8 g/dL and, calcium 10 mg/dL, blood urea nitrogen 21 mg/dL, and creatinine of 2.1 mg/dL. His neurological exam was normal except mild weakness in hip flexor on the left. Because of continued left–sided pain, he had MRI of C–spine which showed diffuse bone marrow signal abnormality. The findings were consistent with metastasis, multiple myeloma, or other lymphoproliferative diseases. A workup for multiple myeloma was initiated. His skeletal bone survey was negative. His protein electrophoresis showed M–spike at 2.9 g/dL and an abmormal band in the gamma region on protein electrophoresis. The immunofixation revealed an IgG lambda monoclonal band. He underwent bone marrow biopsy which confirmed the diagnosis of multiple myeloma with poor prognostic cytogentics. He has undergone several rounds of chemotherapy and is waiting for autologus stem cell transplant.
Although back pain is a frequent presenting symptom in multiple myeloma, hemialgia has not been reported. Many different types of musculoskeletal pains have previously been reported in patients with multiple myeloma. This patient’s pain was dull and aching in nature suggesting that lesions had not reached the periosteum that is enriched with nerves. Involvement of periosteum can lead to periodic shooting and burning sensation in the extremities. A rapid escalation of pain or pain associated with muscle weakness may indicate a fracture or spinal cord compression that needs urgent evaluation. Sudden, severe back pain can be a sign of a fracture or of the collapse of a vertebra in the spine. Nerve impingement can lead to shooting pains in the extremities. Patients with multiple myeloma can also develop peripheral neuropathy and carpal tunnel syndrome.
It is important that in elderly patients with any kind of boney pain to consider multiple myeloma particularly in the setting of kidney disease and/or anemia.