|Year : 2022 | Volume
| Issue : 2 | Page : 207-209
Bacterial meningitis as the first presentation of multiple myeloma
Sasmita Zutushi1, Samarth Shukla2, Sourya Acharya3, Amol Bhawane4, Preeti Mishra2, Satyam Singh3
1 Department of Critical Care, Datta Meghe Institute of Medical Sciences (Deemed to be University), Jawaharlal Nehru Medical College, Wardha, Maharashtra, India
2 Department of Pathology, Datta Meghe Institute of Medical Sciences (Deemed to be University), Jawaharlal Nehru Medical College, Wardha, Maharashtra, India
3 Department of Medicine, Datta Meghe Institute of Medical Sciences (Deemed to be University), Jawaharlal Nehru Medical College, Wardha, Maharashtra, India
4 Department of Nephrology, Datta Meghe Institute of Medical Sciences (Deemed to be University), Jawaharlal Nehru Medical College, Wardha, Maharashtra, India
|Date of Submission||18-Feb-2022|
|Date of Acceptance||28-Jun-2022|
|Date of Web Publication||23-Aug-2022|
Department of Pathology, Datta Meghe Institute of Medical Sciences (Deemed to be University), Jawaharlal Nehru Medical College, Sawangi, Meghe, Wardha - 442 004, Maharashtra
Source of Support: None, Conflict of Interest: None
Multiple myeloma (MM) is a monoclonal gammopathy. Patients with MM are vulnerable to infections, especially by encapsulated bacteria. These infections have been associated with severe morbidity and mortality in MM. A key underlying cause of the immune system's decline in MM is insufficient production of polyclonal immunoglobulin, which manifests as severe hypogammaglobulinemia. An acute bacterial infection is rarely the first sign of the disease. We present a case of a 65-year-old male who presented to us with fever and disorientation. Clinical examination revealed signs of meningeal irritation. Cerebrospinal fluid study confirmed bacterial meningitis. Associated features such as renal failure, high erythrocyte sedimentation rate, hyperglobulinemia, and anemia lead to suspicion of MM which was later confirmed by serum electrophoresis.
Keywords: Bacterial infections, meningitis, multiple myeloma
|How to cite this article:|
Zutushi S, Shukla S, Acharya S, Bhawane A, Mishra P, Singh S. Bacterial meningitis as the first presentation of multiple myeloma. J Sci Soc 2022;49:207-9
| Introduction|| |
In multiple myeloma (MM), there is uncontrolled proliferation of plasma cells resulting in the formation of a monoclonal immunoglobulin, which proliferates and overwhelms the bone marrow. Infections usually occur within 3 months of diagnosis and/or at initiation of chemotherapy., Several evidences suggest that the poor prognostic indicators of MM are male sex, age more than 75 years, declining performance status of the patient, hypercalcemia, raised lactate dehydrogenase, hypoalbuminemia, low body mass index, and early infections., The mortality in MM cases because of infections can be up to 65%.,
| Case Report|| |
A 65-year-old male presented to the emergency department (ED) of this hospital with chief complaints of back pain for 15 days, as well as altered mental status with fever for 4 days. The patient was relatively alright 15 days back when he developed low back pain which was continuous, dull aching type and was aggravated especially at night. There was no radicular pain, bladder and bowel incontinence, and weakness in the lower limb. The patient visited a private hospital for the back pain and was treated with pain killers. The back pain continued at home, and 4 days before the admission, he developed fever and altered mentation as history given by relatives. There was no history of vomiting, convulsions, cough, and dyspnea.
On examination in the ED, the patient was febrile (temperature -38.3°C) and tachycardic (heart rate -131 bpm). Blood pressure was 80 mmHg systolic. Central nervous system (CNS) examination revealed a Glasgow coma scale of 7 (E-2, M-3, V-2), with positive neck stiffness and Kernig's sign. He was then admitted to the medical intensive care unit.
Laboratory investigations revealed anemia (Hgb 7.9 g/dL), total leukocyte count - 14,500/mm3 with 90% neutrophilia, blood urea -102 mg/dL, serum creatinine -5.4 mg/dL, total protein -10 g/dL, albumin -2.8 g/dL, and globulin -7.2 g/dL. Erythrocyte sedimentation rate (ESR) was 112 in the 1st h. Cerebrospinal fluid (CSF) analysis revealed increased total protein (615 mg/dL), increased white blood cell (WBC) (146 cells/mm3) with neutrophils (80%), and decreased glucose (24 mg/dL). The adenosine deaminase level in the CSF was 8 U/L (normal <40 U/L). Gram stain of CSF was negative, and CSF culture revealed Gram-positive diplococci. A diagnosis of bacterial meningitis was kept, and the patient was started on intravenous (IV) fluids: ceftriaxone 2 g IV 12 hourly, injection (inj.) vancomycin 1 g IV 12 hourly, inj. ampicillin 2 g IV 4 hourly, and dexamethasone 10 mg IV 6 hourly, starting 20 min before the antibiotics were started, along with vasopressor and other medications.
MM was suspected due to infection, elevated ESR, hyperglobulinemia, anemia, and renal failure. Urine for Bence Jone's protein was negative. Serum protein electrophoresis revealed the presence of a distinct M-band (3.5 g/dL) in the beta 2-region [Figure 1]. In immunofixation and immunoglobulin quantitative assays, the patient's alpha 1 and 2-microglobulin levels were both abnormally high, at 5.6 and 55.4 μg/L, respectively. A skeletal survey revealed no osseous lytic lesions. A bone marrow biopsy revealed features of MM [Figure 2].
|Figure 1: Serum protein electrophoresis showing M-band in beta 2 region. Ref. = Reference, Conc. = Concentration, A/G ratio = Albumin to Globulin|
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|Figure 2: Bone marrow smears obtained with Leishman's stain showing plasmacytosis. Plasma cells population is composed of both mature and immature plasma cells. Mature cells have abundant deeply basophilic cytoplasm with perinuclear hof, eccentric nuclei (with coarse cart wheel chromatin). Immature plasma cells showing binucleation and mild pleomorphism (a, high power view, ×40 and b, oil immersion view, ×100)|
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Chemotherapy was postponed due to the current infection. The patient was managed with empirical antibiotics, IV fluids, two sessions of hemodialysis, ventilatory and vasopressor support, and steroids. After 9 days, the patient succumbed to his illness.
| Discussion|| |
MM is characterized by the multiplication of plasma cells that produce enormous amounts of monoclonal antibodies. The sentinel episode of infection is usually more common in the first 3 months after a diagnosis of MM, according to Chapel and Lee. The next vulnerable period for acquiring infections is within first 3 months of chemotherapy in 75% of cases. The bulk of these bacterial infections are of respiratory or urinary tract.
In MM, T cells are prevented from entering an inflammatory pathway, which stops cytokine secretion., In both stable and advancing MM, transforming growth factor-β or interleukin (IL)-10, or both, has been shown to diminish T cells expressed by dendritic cells (DCs). DCs then produce a lot of IL-10 and relatively little IL-12, lowering their effectivity.
In MM, the signaling molecules such as T-helper 17 cells which inhibit bacterial penetration into the mucosal cells are dysfunctional., B-cells inhibition causes polyclonal hypoglobulinemia, which is common in MM.,
Patients with MM are at a higher risk of infection, particularly from encapsulated bacteria such as Streptococcus pneumoniae. Meningitis and pneumonia are the most dangerous forms of infections in MM.,,,,
Patel and Nikcevich described a case of pneumococcal meningitis as the first presentation of MM. They hypothesized an underlying immunodeficiency because a stained CSF smear revealed numerous extracellular Gram-positive diplococci, indicating a lack of complement activation. Despite high CSF bacterial concentrations, WBCs (0–20/mm3) have been associated with a bad outcome.
| Conclusion|| |
MM is a monoclonal gammopathy where there is a clonal proliferation of a single immunoglobulin by malignant plasma cells. It usually occurs in elderly males and presents with bone pains, renal failure, and anemia. Infections are commonly associated with MM because of immune dysfunction. Most common sites are respiratory and genitourinary, but rarely, CNS infections can be the primary manifestation. Any elderly male presenting with serious systemic infections and other associated features such as renal failure and skeletal symptoms should alert the treating physician to rule out MM by appropriate investigations.
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Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2]