A case of multiple myeloma presenting as scalp swelling with intracranial extension
A 35-year-old female presented to us with complains of rapidly progressing scalp swelling over left side of head for last 4 months, weakness of right hand followed by right lower limb for last 30 days, and simple partial seizure of right upper limb for last 15 days. She was anemic without lymphadenopathy or organomegally. We found a tense globular swelling over left frontal area of size 10-10-6 cm, with variegated consistency. This was fixed to underlying skull and skin. There was no visible impulse on cough, pulsation, or bruise over the swelling. There was an ulcer of about 2 cm in diameter situated over lateral aspect of swelling with signs of inflammation surrounding it [Figures and ]. X-ray skull [], contrast enhanced computed tomography (CECT) of brain [], and contrast magnetic resonance imaging (MRI) of brain [Figures –] were suggestive of an osteolytic skull lesion with intra cranial extension. Cerebral angio MRI showed a highly vascular tumor with patent superior longitudinal sinus []. She was advised for preoperative tumor embolization, because of her financial constrain it was not carried out. Her laboratory examinations were within normal range except erythrosedimentation rate (60 mm/h) and hemoglobin 8 g/dl. Work up for common metastatic lesions from breast, thyroid, kidney, and lungs were negative. Meningioma with malignant transformation, metastatic lesions, and plasmacytoma were kept as differential diagnosis.\nAn elliptical incision was given over the swelling taking ulcer in between the incision margins. We found a highly vascular, soft pinkish tumor eroding the skull bone and invading scalp layers []. Most of the extra cranial portion was excised, because of severe bleeding patient went into shock. Patient revived after 4 units of blood transfusion. We went for second surgery, 7 days after first one. Dura margin was delineated by rongering out bone circumferentially around tumor margins. Tumor was found infiltrating dura and invading parenchyma []. Dura excised along with adherent residual extracranial tumor followed by excision of invading intracranial tumor done []. Duroplasty was done with synthetic dural substitute []. Histopathological study of tumor sample came as plasmacytoma [Figures and ]. On immunohistochemical staining, tumor cells were negative for CD-20 [] and positive for CD-138. Bone marrow aspiration study showed increase in number of plasma cells, constituting 30% of marrow nucleated cells. Both bi- and trinucleated plasma cells were seen []. Serum protein electrophoresis showed monoclonal “M” spike and screening skeletal X-ray failed to found other lytic lesion. Final diagnosis was multiple myeloma. Postoperatively, local radiotherapy (50 Gy) and chemotherapy (three cycles of melphalon plus dexamethasone) were given. At 3-month follow up, the patient is doing well with no local recurrence.