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A4061 - A Diagnostic ""Tap"": The Use of Thoracentesis in the Diagnosis of Pulmonary Plasmacytoma
Author Block: W. Rodriguez1, Y. Otero-Dominguez1, A. Candelario2, L. Gonzalez1, O. J. Cantres3; 1Pulm/CCM/Sleep, VA Caribbean Healthcare System, San Juan, PR, United States, 2VA Caribbean Healthcare System, Guaynabo, PR, United States, 3VA Caribbean Healthcare System, San Juan, PR, United States.
Solitary extramedullary plasmacytomas is a rare presentation of multiple myeloma and represent approximately 3% of the plasma cell malignancies. Extramedullary plasmacytoma are most commonly associated with the nasopharynx or paranasal sinuses. Manifestation within the lung parenchyma are uncommon. Plasmacytoma of the lung may present as a pulmonary nodule or hilar mass. An 83-year-old male patient former smoker with past medical history of Hypertension, Hyperlipidemia, Diabetes Mellitus, Coronary Artery Disease s/p Coronary Artery Bypass Graft 10 years ago, Hypothyroidism, and Depression was brought to the Emergency Room due to a 3-day history of shortness of breath that worsened during the morning. The patient denied cough, sputum production, or hemoptysis. He quit smoking more than 20 years ago. The patient admitted long standing general weakness that worsened in the past week. He denied fever or chills. The patient admitted anorexia, and unintentional weight loss. On laboratory review, complete blood count was unremarkable without leukocytosis or anemia. Chemistry showed normal calcium and creatinine levels. Upon evaluation with a chest X-ray, the patient had almost complete opacification of the left hemithorax with mild shifting of the mediastinum to the right side suggesting a large pleural effusion and left lung mass. Further evaluation with a chest computed tomography (CT) scan confirmed the findings, and revealed a new large soft tissue mass (14.5 x 10.2 x 6.3 cm) located at the anterolateral left chest wall at the level of the lung base with associated rib destruction. A thoracentesis was performed. A total of 1,500mL of bloody fluid were removed and pleural fluid analysis was suggestive for an exudative pleural effusion. Cytologic fluid examination was positive for proliferation of atypical plasmacytic cells. Serum beta-2 microglobulin were elevated (7.73mg/L). A serum protein electrophoresis (SPEP) with immunofixation and quantitation of immunoglobulins was remarkable for an M-spike (5.2g/dL). In order to confirm the patient’s final diagnosis a CT guided needle biopsy from left costal wall mass was obtained. The pathology report was consistent with a neoplastic plasma cell disorder, specifically a plasma cell myeloma. Approximately 1% of the plasma cell myeloma cases are associated with a myelomatous pleural effusion. This case represents a rare presentation of plasma cell myeloma in the form of solitary pulmonary plasmocytoma. It also draws attention to the fact that this pathology can be diagnosed through pleural fluid analysis which represents a less invasive approach than standard CT guided biopsy.