Prepared by Herbert L. Fred, MD, Professor of Medicine, The University of Texas Health Science Center, Houston, and Richard Guerrero, MD, Resident, Bennett Ezekiel, medical student, and Sheena G. Stubbers, MD, Assistant Professor of Medicine, Texas Tech University Health Science Center, El Paso

A 68-year-old man presented with pleurisy and cough of 2 weeks’ duration. Physical examination, complete blood cell count, and urinalysis were all normal. A chest radiograph showed 3 large masses (Figure 1), each contiguous with a partially destroyed rib (Figure 2). Lytic lesions were also evident in the calvarium and left femur. The serum calcium level was elevated at 13.5 mg/dL (normal, 8.4-10.2 mg/dL), and serum electrophoresis showed a monoclonal spike of 4.4 g/dL. Biopsy specimens from bone marrow and one of the rib masses showed sheets of plasma cells, confirming the diagnosis of multiple myeloma.

Figure 1 - Chest radiograph revealing 3 large masses.	Figure 2 - Close-up of mass showing partially destroyed rib (arrowheads).

Points to remember: The combination of hypercalcemia, lytic bone lesions, and a high monoclonal spike strongly suggests multiple myeloma. Definitive diagnosis, however, requires bone marrow examination or biopsy of a suspicious bone lesion.

Chest disease associated with multiple myeloma can manifest as infection or as bone lesions, complicated at times by pleural effusion. A bone lesion may expand and appear radiographically as a "lung mass."

Diagnosis: Multiple myeloma.