Pc Sanchetee

PLASMA CELL MYELOMA PRESENTING AS ACUTE CONSTIPATION

Plasma cell myeloma or multiple myeloma is an uncontrolled proliferation of plasma cells in the marrow. The neoplastic cells synthesise abnormal amount of monoclonal immunoglobulins or alpha or lambda light chains [1]. Clinical manifestations of myeloma vary and include bone pains, hypercalcaemia, anaemia, hypogammaglobulinemia, and spinal cord compression etc. [1, 2]. We report here one such case who had an unusual presentation of acute constipation. Case Report A 45-year-old male patient first presented with acute constipation and pain rectal region of 3 days duration. Initially he attributed it to acute exacerbation of fissure-in-ano which he developed 5 years ago. However, clinical examination including per rectal and proctoscopic examination was normal. For next 5 days he was managed with repeated glycerine enema and laxatives but without any relief. At this stage he was subjected to a detailed evaluation. Endoscopic examination of colon, stomach and duodenum failed to detect any abnormality. He was also evaluated for underlying psychiatric disorder but without any positive finding. In view of intractability of symptoms he was referred to us on eleventh day of his illness. A detailed history revealed that at onset he had transient vague pain over the chest at the level of nipple for 2 days. He also gave history of numbness and paraesthesia over lower limbs and hesitance for micturition of 3 days duration. There was no history of pain in the spine or other bones, fever, headache, weight loss, recurrent infections, bleeding diathesis or trauma. There was no history of hypertension, diabetes mellitus or tuberculosis in the past. Clinical examination revealed him to be obese with height 165 cms and weight 80 kgs. There was no pallor, lymphadenopathy or bony tenderness. Neurological examination revealed hypoaesthesia below D6 dermatome (right side being affected more than left side) and weakness in lower limbs. Deep tendon reflexes were sluggish in lower limbs. Abdominal reflexes and plantar reflexes were absent on both sides. There was no papilloedema or signs of meningeal irritation. Tenderness was present over D4 and D5 spine. Examination of other systems was within normal limits. Investigations revealed Hb 12.4 gm per cent, TDLC 6700/cmm with P 59 L38 M2 E1 per cent, ESR 120 mm fall first hour, blood urea 29 mg per cent, serum creatinine 1.0 mg per cent, blood uric acid 8.0 mg per cent and serum calcium 9 mg per cent. Radiograph of chest PA view and 12-lead electrocardiogram were normal. Radiograph of skull, pelvis and long bones in the limbs showed multiple punched out lytic lesions. Scrum electrophoresis showed monoclonal gammopathy, Monoclonal (M) spike in the beta-gamma interzone alongwith hypoalbuminemia and hypogammaglobulinemia. Bone marrow study showed marked infiltration by plasma cells (>30%) with reduction in erythroid and myeloid cells. Magnetic resonance imaging (MRI) of spine demonstrated altered signal intensity of D4-D6 vertebrae. There was an intraspinal soft tissue mass on right side extending from D2 to D5 vertebrae compressing the spinal cord and thecal sac anterioly at that level. There was a paraspinal extension of the mass through intervertebral foramina at D3-4, D4-D6. Radionuclide bone scan showed patchy increased uptake in skull, spine, ribs and major bones of the limbs suggestive of extensive skeletal involvement. Diagnosis of multiple myeloma with myeloradiculopathy was made. He was managed with palliative chemotherapy (vincristine, cyclophosphamide, adriamycin, steroids) and radiotherapy. However, his condition rapidly deteriorated and he died 3 months later.

THE CHANGING FACE OF MEDICAL LIBRARIES

Reading has been a source of joy to man since several hundreds of years. The invention of paper made books widely available and libraries became commonplace. But now the situation is slowly but surely changing. Paper and books are becoming costlier and the popularity of the electronic media is increasing. Medical books and libraries also face competition from the electronic media. The MEDLARS, an excellent example of this technological revolution is now available all across India through the National Informatics Centre and it appears to be very cost effective decision for even peripheral hospitals to acquire a MEDLARS facility.