Diagnostic dilemma in a case of osteolytic lesions

Abstract

A middle-aged male patient presented with fever, polyarthralgia, polyuria, easy fatigability and weight loss for 1 month. Clinically, there was only significant pallor and a swelling over the right sternoclavicular joint. On investigation, there was anaemia, raised urea, creatinine and pus cells in urine with growth ofEscherichia coli. There were also hypercalcaemia and osteolytic lesions over the ribs, scapula, clavicle and skull along with distorted renal corticomedullary differentiation. Although the initial diagnosis was likely to be a case of multiple myeloma, serum protein electrophoresis was negative for the monoclonal band and no Bence-Jones protein was detected in urine. Bone marrow plasma cells were less than 10%, but the serum-free light chain assay revealed altered κ:λ ratio. Later in the course of the disease, a cervical lymph node appeared. The biopsy and immunohistochemistry of this lymph node revealed a CD5 positive diffuse large B-cell lymphoma, but unfortunately the patient succumbed to his illness after receiving the first cycle of Rituximab-Cyclophosphamide-Hydroxydoxorubicin-Oncovin-Prednisolone.

Hypercalcaemia, renal dysfunction, anaemia and bone lesions (CRAB) do not always represent multiple myeloma: diffuse large B cell lymphoma presenting with CRAB symptoms in a 69-year-old man

“…There are always exceptions in medicine, and this should be taken into account for diagnosis. This is an important reminder that patient’s with a particular presentation may be misdiagnosed or mistreated or at least delayed diagnosis if we are not diligent enough, as previously highlighted by Mandal et al 21…”

“…However, it is rare for NHLs to present with hypercalcaemia and lytic bone lesions like our patient as an initial presentation. Through our literature review, we came across seven such cases reported previosuly 7 8 21–24. These are presented in table 1.…”

Hypercalcemia (C), renal dysfunction (R), anemia (A), and lytic bone lesion (B) (CRAB) as presenting features in non myelomatous malignancies: A case report and review of the literature

“…CRAB like initial presentation mimicking active myeloma is uncommonly reported in the literature. [3][4][5][6][7][8][9][10][11][12][13][14][15][16] In this manuscript we describe a middle-aged female subject who presented with clinicoradiological and biochemical features secondary to metastatic breast cancer mimicking CRAB positive myeloma and present a comprehensive review of all such CRAB positive nonmyelomatous malignancies reported in the literature.…”

“…There were twenty-two cases of CRAB positive nonmyelomatous malignancies (M:F = 1:1) the details of which are briefly summarized in Table 1. [3][4][5][6][7][8][9][10][11][12][13][14][15][16] The median age at presentation was 58. G reversal was described in a case reported by Roy et al in a case of primary osseous Burkitt lymphoma.…”

“…17 Data pertaining to serum ALP was not available or the same was not done in 17/22 (77.2%) cases; and in remainder four cases (where available), it was found to be elevated (237 [case 2], 219 [case 7], 177 [case 10], 263 U/L [case 11]). 5,10,13,14 and metabolic bone disease work up were not available in most of the cases. All patients received intravenous hydration, diuretics, and calcitonin in some with good clinical response.…”