Multiple atypical presentations in a case of multiple myeloma in an elderly female

A 68-year-old Indian female, from Muslim community, presented to our outpatient department with complaints of generalized fatigue for 3 months. She had no history of dyspnoea, pedal oedema or bleeding from any sites of the body. She was pale with no icterus, clubbing, palpable lymph nodes or organomegaly. Her haemoglobin was 5.8 g/dL (normal: 12–16 g/dL), total leukocyte count (TLC) of 2300/mm (normal: 4000–11000/mm), and platelet count of 70,000/mm (normal: 250,000–400,000/ mm). TLC consisted of 40% neutrophils, 55% lymphocytes, 3% monocytes, 1% basophils and 1% eosinophils. Mean corpuscular volume was 105 fl (normal: 86–96fl). Corrected reticulocyte count was 1.5%. Erythrocytic sedimentation rate (ESR) was 90 mm in 1st hour (normal: 20–30 mm in 1st hour). Serum lactate dehydrogenase level was 350 IU/L (normal: 105–333 IU/L). Peripheral smear showed only pancytopenia. (Fig. 1) Serum Vitamin B-12, folate, Methyl-malonic acid (MMA) and homocysteine were in normal range. Bone marrow aspiration revealed fairly cellular marrow with 23% plasma cells (Fig. 2) including atypical cells. Bone marrow biopsy had 100% marrow cellularity with sheets of plasma cells. Her urea and creatinine levels were 30 mg/dL (normal: 20– 50 mg/dL) and 0.9 mg/dL (normal: 0.5–1.8 mg/dL) respectively. Total calcium level was 8.9 mg/dL (normal: 8.1–10.4 mg/dL). She had albumin level of 3.8 g/dL (normal: 4.0–5.5 g/dL) and globulin of 5.6 g/dL (normal: 3.8–4 g/dL). Erythropoietin level was 15mU/ mL (normal: 1–29 mU/mL).