Lung biopsies from four children and two adults with idiopathic pulmonary haemosiderosis have been examined by transmission electron microscopy. No qualitative differences were identified between the children and the adults but the changes were more severe in the children. In each case the major damage involved the capillary endothelium and its basement membrane. Capillary endothelial swelling was very noticeable and in one case the endothelium was attenuated but gaps between endothelial cells were very difficult to find. Capillary narrowing and platelet aggregation were common. The capillary endothelial basement membrane showed focal thickening, particularly on the thick side of the air/blood barrier, but no electron dense deposits were identified. Degenerative changes in the alveolar epithelium were not so marked as those in the capillary endothelium and the epithelial basement membrane was normal except for haemosiderin deposition. Haemosiderin was also noted on elastin and within intra-alveolar macrophages. Other secondary changes included mild interstitial oedema and fibrosis. These findings indicate that the major site of damage is the alveolar capillary, but provide no evidence of the cause of the disease.

No abstract

Pathological rupture of the spleen in uncomplicated myeloma is extremely rare. We present a case of a splenic rupture which occurred in a 52 year old woman with uncomplicated multiple myeloma. The patient required an urgent splenectomy and had an uneventful recovery. Pathophysiological mechanisms leading to splenic rupture are discussed. Plasma cell leukaemias have been previously documented to present with splenic rupture. A subgroup of aggressive multiple myelomas such as in our case may have a similar tendency for splenic rupture.Keywords: spleen, rupture, myeloma A 52 year old woman was diagnosed with multiple myeloma ISS Stage III in 2006. Her past medical history was signifi cant for diet-controlled diabetes mellitus and hypertension. She had a background of a few months of right hip pain and a pathological femoral fracture had been noted on plain fi lms. A right total hip replacement was performed and a bone specimen revealed infi ltration of cells exhibiting features suggestive of plasmacytoma or occult myeloma. Subsequent protein electrophoresis revealed the presence of a lambda protein band of approximately 1 g/l in the gamma region. Her albumin and corrected calcium levels were normal at 40 g/l and 2.36 mmol/l respectively. Her β-2 microglobulin level was recorded as 6.8 mg/l.A bone marrow biopsy performed revealed 85%-90% marrow infi ltration with plasma cells, markedly reduced erythropoiesis and moderately reduced myeloid numbers. She was discharged and plans made for outpatient chemotherapy.One week later she presented to hospital with acute left pleuritic pain. There was notable tenderness over the lower left ribs anteriorly and back. Cardiovascular, respiratory and neurological systems were normal. Her abdomen was soft to palpation, non-tender and there were no masses detectable. Vital sign recordings, chest X-ray and ECG were normal.FBC showed a Hb of 99 g/l, WBC 9.0 × 10 9 /l and platelet 136 × 10 9 /l. Blood fi lm revealed numerous atypical plasma cells representing 7% of cells on peripheral blood. Electrolyte profi le was unremarkable apart from a mild hyperphosphatemia PO4 3-2.00 mmol/l. Coagulation screen showed INR 1.2, APTT 32 and fi brinogen 3.1 g/l.An MRI of the spine did not reveal any signifi cant abnormality. A consideration of pulmonary emboli was made as the cause of the pleuritic chest pain and a CT pulmonary angiogram ordered on the 3rd day of admission. She was anticoagulated with subcutaneous enoxaparin pending the result of the investigation. The CT pulmonary angiogram did not reveal pulmonary emboli but a markedly enlarged spleen was noted with a wedge-shaped low density area located posteriorly in the spleen and a small adjacent hyperdense area. The radiological fi nding was thought to be consistent with a splenic infarct and associated haemorrhagic transformation. See Figure 1.Subcutaneous enoxaparin was discontinued and the putative splenic infarction was managed conservatively with analgesia.The next day the patient developed pain in the lower chest radiating to...