A 52-years old man presented to our clinic with chest and back pain lasting for 3 months. On the chest radiography, pleural fluid was detected in left hemithorax (). On thorax CT, it was also detected that there were lytic bone lesions at level of 11th and 12th ribs and pleural thickening at paravertebral site on the left. In laboratory evaluations, following findings were observed: hemoglobin: 7.1g/dl.(14–18), white blood cells:11.26 × 103/μL(4.8–10.8), platelets: 787 × 103/μL., creatinine: 3.1mg/dl.(0.6–1.1).Uric acid: 6.1 mg/dl (2.6–6), calcium: 14.7mg/dL (8.8–10.6), total protein:10.7g/dL (6.4–8.3), albumin: 1.8g/dL (3.5–5.2). Serum protein electrophoresis revealed a hypoalbuminemia (21.1%; range; 55.8–66.1) associated with an increase in γ globulins (42.1%; range; 11.1–18.8). IgG-Kappa monoclonal paraproteinemia was detected in immunofixation tests (IgG: 4460mg/dL. reference interval, 850–1330; Kappa: 1640mg/dL, reference interval, 630–1350). ß-2 microglobulin was found as 2.71 mg/dlL (reference interval: 1.42–3.21). Bence-Jones protein was found to be negative in 24-hours urine collection. A thoracentesis was performed, which revealed serofibrinous fluid with a protein level of 6.3gr/dl and white blood cell count of 6.65 × 103μL consisting of lymphocytes (80%) and neutrophils (20%).
Chest radiograph showing pleural effusion on the left
Bacterial and micobacterial culture tests of pleural fluid were reported as negative. Biopsy was performed on the mass at rib, which was reported as CD138(+), CD20(−) plasmocytoma. Pleural fluid flow cytometry was performed by using FACSCalibur flow cytometer (Becton-Dickinson, Erembodegem, Belgium). In the flow cytometry, CD56, CD38 and CD138 found to be positive, while CD19 was negative. Bone marrow biopsy was reported as CD38 (+) and CD20(−) atypical plasma cell infiltration. T(4;14), 17p13,1 (p53 gene) and 13q14,3(Rb gene) was found as negative by FISH method.
The patient was scheduled for VAD (vincristine, doxorubicin, dexamethasone) chemotherapy, biphosphonate therapy and involved-field radiotherapy.