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Case 366


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Male patient, 36 years old, referring severe low back pain and refractory to painkillers for 3 months, associated to painful irradiation to the posterolateral region of the right tight. Reports unintentional weight loss of 7kg for the last 4 months. Laboratory tests: hemoglobin: 9.5g/dL; serum creatinine: 3.2mg/dL; total calcium: 14.7mg/dL; ionized calcium: 8.5mg/dL; phosphorus 4.7mg/dL and serum protein electrophoresis: monoclonal proteins of 2.82g/dL and 43.9% β-2 globulin fraction.

Based on the images and the clinical history, which of the following diagnosis is the most likely?

a) Waldenstrom’s macroglobulinemia


b) Primary hyperparathyroidism


c) Metastatic prostate cancer


d) Multiple Myeloma


Image analysis


Image 1 - Analysis: Computed Tomography (CT) of the lumbar spine, median sagittal reconstruction, soft tissue window. Presence of many osteolytic lesions on the spine (some are pointed by the red arrows), compromising the structure of vertebral bodies and spinous processes of the lumbar spine and sacrum. Osteolytic lesion in the L5 vertebral body, projecting into the spinal canal (arrowhead).


Image 2 - Analysis: Computed Tomography (CT) of the lumbar spine, axial plane, L5 level, soft tissue window. Presence of osteolytic lesions in the L5 vertebral body and in its right transverse process (red and black arrows, respectively). Osteolytic lesion, seen in Image 1, highlighted (red dotted), with frank destruction of the vertebral body, projecting into the spinal canal.


- Multiple myeloma is a neoplastic disease, resulting from the proliferation of plasma cells;

- It mainly affects individuals over 70 years old and rarely, under 40 years old;

- It is manifested clinically by: bone pain, anemia, impaired renal function, and hypercalcemia;

- In imaging exams, it is characterized by the presence of lytic lesions in the axial skeleton, usually without surrounding sclerotic activity;

- The diagnosis is based on the finding of bone marrow infiltration by plasma cells and the characterization of lesions in target organs;

- Its treatment, although not curative, allows to suppress its evolution and to mitigate its organic repercussions.


-Dimopoulos M, Terpos E, Comenzo RL, Tosi P, Beksac M, Sezer O, et al. International myeloma working group consensus statement and guidelines regarding the current role of imaging techniques in the diagnosis and monitoring of multiple Myeloma. Leukemia . 2009;23(9):1545–56.

- Kumar SK, Rajkumar V, Kyle RA, van Duin M, Sonneveld P, Mateos M-V, et al. Multiple myeloma. Nat Rev Dis Prim. 2017 Jul 20;3:17046. 

-Palumbo A, Anderson K. Multiple Myeloma. N Engl J Med. 2011 Mar 16;364(11):1046–60

-Munshi NC, Longo DL, Anderson KC. Plasma cell disorders. In: Kasper DL, Hauser SL, Jameson JL, Fauci AS, Longo DL, Loscalzo J, editors. Harrison’s principles of internal medicine. 19th edition. New York: Macmillan Publishers Limited; 2017. p. 710–9. 

-Rajkumar VS. Multiple myeloma: Clinical features, laboratory manifestations, and diagnosis. In: UpToDate, Post, TW (Ed), UpToDate, Waltham, MA, 2019. Accessed on May 17, 2019. 


Bruno Jordão Chaves, 5th year medical student at Universidade Federal de Minas Gerais.

E-mail: bruno.jordao07[at]


Ana Flávia Leonardi Tiburcio Ribeiro, medical hematologist and adjunct professor of the Department of Internal Medicine at Universidade Federal de Minas Gerais.

E-mail: anatiburcio[at]


José Nelson Mendes Vieira, medical radiologist and professor of the Department of Anatomy and Image at Universidade Federal de Minas Gerais.

E-mail: zenelson.vieira[at]


Leandra Prates Diniz, Gustavo Vargas Borgongino Monteiro, Mirella Monique Lana Diniz, Letícia de Melo Elias, Professor Viviane Santuari Parisotto Marino.

Translated by

Leandra Prates Diniz, 5th year medical school at Universidade Federal de Minas Gerais

E-mail: leandraprates[at]

Test question












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