CRA43 THE UNEXPECTED GUEST: WHEN GRANULOMAS HIJACK A MYELOMA WORKUP

Jason Tan Seng Hong¹, Nor Syazana Jamali², Navin Kumar Santha Moorthy³, Tee Teng Teng⁴

¹Department of Medicine, Hospital Banting, Selangor, Malaysia
²Department of Pathology, Hospital Banting, Selangor, Malaysia
³Department of Radiology, Hospital Banting, Selangor, Malaysia
⁴Department of Medicine, Hospital Tengku Ampuan Rahimah, Klang, Selangor, Malaysia

Introduction
Sarcoidosis is a systemic inflammatory disease, forming non-caeseating granulomas commonly in the lungs and lymph nodes. We describe a case of sarcoidosis that was discovered during workup for plasma cell myeloma (PCM).

Case Report
A 62-years-old lady with multiple co-morbids presented with acute pancreatitis and constitutional symptoms. She denied any respiratory symptoms. PCM was suspected in view of non-PTH dependent hypercalcemia, full blood picture showing normocytic anemia with rouleux formation, worsening renal function, and serum and urine electrophoresis showing IgG lambda paraproteinemia. However, bone marrow trephine biopsy showed dense collections of non-caseating granuloma with no findings of PCM and was negative for Mycobacterium tuberculosis and fungi. Chest X-ray and spirometry were normal. Computed tomography (CT) thorax showed extensive symmetrical perilymphatic nodularity with no mediastinal lymphadenopathy. Her hypercalcemia responded well with a tapering course of steroids.

Discussion
Patient had asymptomatic pulmonary sarcoidosis stage III and hypercalcemia secondary to bone marrow sarcoidosis which is a rare form of extrapulmonary presentations. Hypercalcemia is common but rarely the initial presentation in sarcoidosis. Patients with higher radiographic stages tend to have more pulmonary symptoms, greater functional impairment and lower likelihood of resolution. CT thorax is more sensitive in assessment of pulmonary sarcoidosis. Corticosteroids remain the cornerstone of treatment, with the aim to reduced inflammation, leading to better symptom control and outcomes.

Sarcoidosis usually does not have monoclonal gammopathy, differentiating it from PCM. However, this patient had concurrent monoclonal gammopathy of unknown significance which required surveillance since sarcoidosis does associated with higher risk of lymphoproliferative diseases, and concomitant existence of the two have been reported.

Conclusion

Sarcoidosis should be considered as one of the differential diagnosis in hypercalcemia especially in patients of certain ethnicity despite negative pulmonary symptoms and normal chest radiography.