ISOLATED PITUITARY MASS: A RARE MULTIPLE MYELOMA PRESENTATION Lane Maley MD, James Peeples DO, Josh King MD, Graham Unis MD; Department of Medicine, Ochsner Clinic Foundation, New Orleans, LA.
Introduction: Isolated pituitary mass is a rare presentation of multiple myeloma, and to date it has predominantly been described in case reports. Case: A 57-year-old female patient with anemia, hypothyroidism, and recent motor vehicle accident resulting in vertebral compression fractures presented with a one-month history of progressive fatigue, dyspnea, weakness, and anorexia. She reported that her decreased oral intake was due to a painful tongue, which appeared edematous and erythematous on examination. Her labs at presentation were notable for pancytopenia with hypoproliferative marrow, elevated alkaline phosphatase, and acute kidney injury. Hematology was consulted and a serum protein electrophoresis, free light chains, and quantitative immunoglobulin levels were obtained. The patient continued to have progressive neck pain and neurosurgery was consulted for suspicion of worsening vertebral fractures. A Computed Tomography (CT) of her head revealed a 3-centimeter mass within the sphenoid sinus with bony erosive changes suspicious for
neoplasm. A CT of the pelvis showed abnormal signal intensity in the bone marrow. Free light chain analysis was consistent with multiple myeloma, and biopsy of clival mass was diagnostic of a plasma cell neoplasm. The patient was discharged with oncology follow-up for bone marrow biopsy and treatment planning. Discussion: Plasmacytoma of the pituitary is a rare presentation of multiple myeloma. It more commonly precedes multiple myeloma, but not all cases of plasmacytoma progress to multiple myeloma. Pituitary plasmacytoma is often mistaken for non-functioning pituitary adenoma. Plasmacytoma is much more likely to present with cranial neuropathies than a benign pituitary adenoma, however our patient had no cranial neuropathies at the time of presentation. This case demonstrates the difficulty in distinguishing between benign adenoma and plasmacytoma, and it is further evidence that plasmacytoma should be considered in the differential of pituitary masses.
ACQUIRED AMEGAKARYOCYTIC THROMBOCYTOPENIA: A PRECURSOR TO APLASTIC ANEMIA Courtney Baldwin DO; Department of Medicine, Ochsner Medical Center, New Orleans, LA.
Introduction: Acquired amegakaryocytic thrombocytopenia (AATP) is a rare, hematologic disorder that causes a reduced or absent number of megakaryocytes in the bone marrow with preservation of other cell lineages later in life. It is more often seen as a congenital, autosomal recessive disease within the first month of life. The etiology of AATP is varied and it is commonly misdiagnosed as immune thrombocytopenia (ITP). Treatment with intravenous (IV) steroids and immunoglobulin for ITP is ineffective for AATP and should warrant further investigation with a bone marrow biopsy. Case: A 25-year-old female with attention deficit hyperactivity disorder, anxiety/depression, vitamin B12 deficiency and iron deficiency presents with thrombocytopenia. She was recently seen at an Urgent Care for menorrhagia and her platelet count was 33,000 cells/microliter prompting her to come to the hospital. She endorsed transient petechiae on
her upper extremities for the past several months. She denies clinically significant bleeding such as epistaxis, hematuria, melena, or hemoptysis. She previously had a B12 injection for a level of 172 pg/ ml that was normal on recheck. Nutritional studies, hemolysis labs, and viral studies were negative. She was started on dexamethasone 40 mg daily for 4 days and IVIG times two doses initially as ITP was suspected. There was no improvement in her platelet count and a bone marrow biopsy resulted with hypocellular marrow for age (40-50%) with megakaryocytic hypoplasia. She was started on Promacta with a platelet count greater than 10k cells/ microliter and a hemoglobin greater than 7 g/dl and twice weekly labs. She had worsening pancytopenia after 2 weeks of Promacta. She had a second bone marrow biopsy 4 weeks later as there was a concern for progression to aplastic anemia. Her second biopsy revealed worsened hypocellular marrow confirming aplastic anemia. She was admitted and started on 27
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