A 68-year-old man presented with pleurisy and cough of 2 weeks? duration. Physical examination findings, complete blood cell count, and urinalysis were all normal. The serum calcium level was elevated at 13.5 mg/dL (normal, 8.4-10.2 mg/dL), and serum electrophoresis showed a monoclonal spike of 4.4 g/dL. Additional findings from a chest radiograph (Figure 1) strongly suggested the diagnosis, which was then confirmed by biopsy.
Diagnosis: Multiple myeloma.
The chest radiograph showed 3 large masses (Figure 1), each contiguous with a partially destroyed rib (Figure 2). Lytic lesions were also evident in the calvarium and left femur. Biopsy specimens from bone marrow and one of the rib masses showed sheets of plasma cells, confirming the diagnosis of multiple myeloma.
The combination of hypercalcemia, lytic bone lesions, and a high monoclonal spike strongly suggests multiple myeloma. Definitive diagnosis, however, requires bone marrow examination or biopsy of a suspicious bone lesion. Chest disease associated with multiple myeloma can manifest as infection or as bone lesions, complicated at times by pleural effusion. A bone lesion may expand and appear radiographically as a "lung mass."
Figure 2—Close-up of mass showing partially destroyed rib (arrowheads).