The patient haematocrit and platelets count continued to drop precipitously. monoclonal paraprotein, is usually second in prevalence amongst hematologic malignancies [1]. The diagnosis of multiple myeloma requires the presence of at least 10% of plasma cells in the bone marrow or the presence of extramedullary plasma cell tumor and at least one of the following clinical manifestation due to plasma cell proliferation: anemia, renal insufficiency, bone lesions, and increased plasma calcium level. More recently in addition to the presence of a monoclonal protein the involved: uninvolved serum free light chain ratio more than or equal to 100 proved to be of diagnostic significance [2]. The clinical presentation with major spontaneous bleeding is uncommon and seldom has been reported in patients with multiple myeloma. Previous retrospective studies demonstrated that bleeding tendency is more common with IgM and IgA paraprotein and the bleeding tendency in such cases has been attributed mainly to the higher serum viscosity due to the accumulation of such immunoglobulins. However, even in such cases, severe symptomatic bleeding as initial manifestation of multiple myeloma has not been reported [3]. We hereby report a first case of IgG lambda multiple myeloma presenting acutely with severe retroperitoneal hemorrhage refractory to all medical interventions representing a challenging diagnostic and management dilemma. 2. Case Report A 64-year-old female with past medical history of hyperlipidemia, osteoporosis, and diverticulosis presented to the emergency department with worsening, debilitating lower back pain of one-month duration. Further history revealed anorexia, low-grade fever, sweating, and shortness of breath for about 3 weeks and 10 pounds of weight loss. One month earlier, she visited the emergency department for right lower quadrant pain and was discharged with the diagnosis of diverticulitis. Laboratory test at that time did not reveal anemia, hypercalcemia, or decreased renal function. An abdominal computed tomography done at that time revealed incidental splenomegaly at 14.5?cm. Further evaluation was deferred to her primary care physician. At this presentation in the Tafluprost emergency Mouse monoclonal to CD23. The CD23 antigen is the low affinity IgE Fc receptor, which is a 49 kDa protein with 38 and 28 kDa fragments. It is expressed on most mature, conventional B cells and can also be found on the surface of T cells, macrophages, platelets and EBV transformed B lymphoblasts. Expression of CD23 has been detected in neoplastic cells from cases of B cell chronic Lymphocytic leukemia. CD23 is expressed by B cells in the follicular mantle but not by proliferating germinal centre cells. CD23 is also expressed by eosinophils. department, the vital signs were stable, and she was pale and cachectic. Abdominal examination revealed rigidity, distention, tender splenomegaly, and Grey Turner’s sign. Neurologic examination of lower extremities revealed weakness and numbness with hyperreflexia. The rest of the physical examination was unrevealing. Laboratory investigation showed the following: white blood cells of 13.8 1000/ em /em L, haemoglobin of 9?g/dL, and platelets of 101 1000/ em /em L. The peripheral smear showed rouleaux formation and plasma cells less than 10%. Earlier laboratory findings showed mild normocytic anemia, thrombocytopenia, and normal white blood count. Internal hemorrhage was greatly suspected given the clinical and laboratory findings. Other laboratory tests were significant for a creatinine of 2.5?mg/dL and a total calcium level of 9.0?mg/dL. Urinalysis was positive for blood and protein, 511?mg/dL. Prothrombin time was slightly elevated 14.2?sec and a normal activated partial thromboplastin time. Biochemical tests revealed a low total protein at 6.5?g/dL and serum albumin was low at 2.7?g/dL. Serum LDH was elevated at 240?U/L (60C160?U/L). Quantitative D-dimer was more than 0.5?mg/L (reference Tafluprost value is less than 0.5?mg/L). Fibrinogen was normal with a value of 194?mg/dL (193C423?mg/dL). Quantitative immunoglobulin showed an increased IgG at 2187?mg/dL and decreased IgA and IgM levels. Serum and urine immunofixation identified a monoclonal IgG lambda. CT abdomen revealed Tafluprost interval worsening of splenomegaly to 20?cm, multiple enlarged lymph nodes, and retroperitoneal haemorrhage extending from the left kidney to the left inguinal region. MRI of lumbar spine done emergently as the lower extremities showed progressive paralysis revealed critical long segment spinal cord compression extending from the T12 to L5 level secondary to medullary canal haemorrhage (Figures ?(Figures11 and ?and22). Open in a separate window Figure 1 MRI of the lumbar spine in sagittal projection showing critical long segment spinal cord compression extending approximately from the T12, left paraspinal intramuscular hematoma level, inferiorly to the L5. Open in a separate window Figure 2 Axial section of MRI at the level of L5 showing left paraspinal intramuscular hematoma. The patient was transferred to the ICU for developing severe haemorrhagic shock. Based on the clinical and laboratory data the diagnosis of multiple myeloma versus plasma cell leukaemia was considered. Plasma cell leukaemia was excluded as the peripheral blood showed less.