Clinical Review

A Mysterious Massive Hemorrhage

Clinicians examined a patient with mixed symptoms to determine whether she should be diagnosed with multiple myeloma or plasma cell leukemia.


Faced with a patient who had a massive retroperitoneal hemorrhage, clinicians from Saint Vincent Hospital in Worcester, Massachusetts, had to decide whether the patient had multiple myeloma or plasma cell leukemia,

The patient, a 64-year-old woman, came to the emergency department (ED) with month-long worsening, debilitating lower back pain. She also had a low-grade fever, shortness of breath for about 3 weeks, and weight loss of 10 pounds.

One month earlier, she had visited the ED for right lower quadrant pain and was discharged with the diagnosis of diverticulitis. An abdominal computed tomography (CT) scan revealed incidental splenomegaly. When she next came to the ED, an abdominal examination revealed rigidity, distention, tender splenomegaly, and Grey Turner’s sign. A neurologic examination revealed weakness and numbness with hyperreflexia in her lower legs. Another CT scan showed that the splenomegaly had worsened, and magneting resonance imaging (MRI) showed a compressed spinal cord.

The patient was in severe hemorrhagic shock and was transferred to the intensive care unit. Based on the clinical and laboratory data, the clinicians excluded plasma cell leukemia, since the peripheral blood showed < 20% plasma cells—the major criterion for diagnosing the condition. In the absence of a bleeding disorder, vascular disease, and anticoagulation medications, the authors say their case illustrates a rare and aggressive form of multiple myeloma. The clinical presentation with major spontaneous bleeding is uncommon. In fact, they say, it’s the first time this type of presentation has been reported in the medical literature.

Source: Alawadhi A, Leb L. Case Rep Hematol. 2016;2016:1-3.

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