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having just received the first dose of chemotherapy&#46;</p><p class="elsevierStylePara">The patient was a 69-year old female&#46; The only relevant history was a peptic ulcer several years before&#44; and the patient did not take any medications chronically or have a family background of kidney disease&#46; The patient was also waiting for an operation to treat a crural hernia&#46; Two months before seeking emergency treatment&#44; the patient&#8217;s plasma creatinine level was 0&#46;9mg&#47;dl&#44; with no anaemia&#44; and with normal urine parameters and chest x-ray results&#46;</p><p class="elsevierStylePara">The patient was admitted to the emergency room with a compromised general state of health&#44; anorexia&#44; and nausea&#46;</p><p class="elsevierStylePara">Anamnesis did not indicate a decreased water intake&#44; but the rhythm of diuresis did&#44; as well as the appearance of nocturia&#44; which previously had not occurred&#46; The patient also had a cough with bloody sputum&#44; dyspnoea upon light exertion&#44; and orthopnoea&#46;</p><p class="elsevierStylePara">Upon questioning&#44; the patient commented that she had received an anti-flu shot one month prior&#44; and had later started treatment with oral calcium and paracetamol &#40;this treatment had been abandoned in the last 15 days&#41;&#46;</p><p class="elsevierStylePara">The physical examination indicated general poor state of health&#46; The patient had a baseline O<span class="elsevierStyleInf">2</span> saturation of 78&#37; and jugular ingurgitation&#46; Pulmonary auscultation revealed crepitation up to mid-level&#44; and the abdomen was globular with pitting oedema in the limbs&#46; The rest of the physical examination was normal&#46;</p><p class="elsevierStylePara">The blood analyses carried out in the emergency room revealed&#58; creatinine&#58; 5&#46;5mg&#47;dl&#44; Na&#58; 136mEq&#47;l&#44; K&#58; 5&#46;4mEq&#47;l&#44; calcium&#58; 10&#46;9mg&#47;dl&#44; pH&#58; 7&#46;30&#44; HCO<span class="elsevierStyleInf">3</span>&#58; 19mEq&#47;l&#44; haemoglobin&#58; 8&#46;8g&#47;dl&#44; haematocrit&#58; 27&#37;&#44; leukocytes&#58; 13&#160;300&#44; and platelets&#58; 133&#160;000&#46; The coagulation analysis was normal&#46;</p><p class="elsevierStylePara">Urine analysis &#40;systematic&#41; resulted in&#58; proteins &#43;&#43;&#44; blood &#43;&#43;&#43;&#44; sediments &#62;40 red blood cells&#47;field&#44; ionogram&#58; Na 41mmol&#47;l&#44; K 52mmol&#47;l&#46;</p><p class="elsevierStylePara">A chest x-ray taken when the patient was hospitalised indicated bilateral increased densities with butterfly patterns &#40;Figure 1&#41;&#44; and the abdominal ultrasound detected homogeneous hepatosplenomegaly and kidneys with normal size and morphology&#44; with no dilation of the urinary tract&#46;</p><p class="elsevierStylePara">With the available data indicating rapidly progressing renal failure&#44; anaemia&#44; and bloody sputum&#44; as well as the increased densities in the chest x-ray&#44; we suspected extracapillary glomerulonephritis and started treatment with 500mg pulses of 6-methylprednisolone&#46; We also started diuretic treatment with a positive response&#44; but with no improvement in renal function&#44; and so we also started renal replacement therapy with haemodialysis&#46;</p><p class="elsevierStylePara">The laboratory blood analysis &#40;ordinary&#41; indicated that the patient had urea concentrations of 185mg&#47;dl&#44; uric acid&#58; 13mg&#47;dl&#44; cholesterol&#58; 254mg&#47;dl&#44; triglycerides&#58; 218mg&#47;dl&#44; GOT&#58; 44U&#47;l&#44; GPT&#58; 81U&#47;l&#44; GGT&#58; 222U&#47;l&#44; albumin&#58; 4&#46;5g&#47;dl&#44; total protein&#58; 6&#46;6g&#47;dl&#44; calcium&#58; 10&#46;4mg&#47;dl&#44; phosphorous&#58; 7&#46;6mg&#47;dl&#44; and ferritin&#58; 915ng&#47;ml&#46; Viral serology for hepatitis B &#40;HBV&#41;&#44; hepatitis C &#40;HCV&#41; and human immunodeficiency virus &#40;HIV&#41; was negative&#46; The immunological analysis demonstrated a normal complement with a decrease in immunoglobulins&#58; immunoglobulin IgG&#58; 174mg&#47;dl &#40;normal&#58; 751-1560&#41;&#44; IgA&#58; 8mg&#47;dl &#40;normal&#58; 82-453&#41;&#44; and IgM&#58; 8mg&#47;dl &#40;normal&#58; 46-304&#41;&#46;</p><p class="elsevierStylePara">Aiming to clarify the cause of the renal failure&#44; we performed a renal biopsy and found&#58; seven glomeruli per plane &#40;one sclerosed&#41;&#59; the other glomeruli had a mesangial expansion matrix with occasional accumulations resembling nodular lesions&#46; Immunofluorescence was negative for immunoglobulins IgG&#44; A&#44; M&#44; C3&#44; and kappa&#44; and positive for lambda in the intratubular sample&#46; We also observed acute interstitial tubular necrosis in the regeneration phase and&#44; most notably&#44; acellular eosinophilic content in the tubules with an accompanying giant cell reaction&#46; There was no interstitial fibrosis or vascular abnormalities&#44; and the final diagnosis was compatible with a myeloma kidney&#46;</p><p class="elsevierStylePara">After receiving the results of the biopsy&#44; the immunological analysis resulted normal &#40;ANA&#44; ANCA&#44; anti-MBG&#41;&#46; In the electrophoretic spectrum we detected two monoclonal peaks with a slight monoclonal component &#40;0&#46;2g&#47;dl&#41;&#46; Proteinuria in urine samples at 24 hours was 0&#46;13g&#47;24 hours&#44; and the electrophoresis of the urine sample detected the elimination of monoclonal light chains &#40;kappa elimination&#58; free kappa&#58; 5&#46;6mg&#47;dl&#41;&#46;</p><p class="elsevierStylePara">We consulted with the haematology department and performed a bone marrow biopsy that was compatible with a type MM malignant monoclonal gammopathy with intense damage and probable compacted bone marrow&#46; The metastatic bone analysis only showed osteoporosis&#44; and did not detect lytic lesions&#46; The full-body MRI &#40;Figure 2&#41; demonstrated extensive infiltration into the marrow including in the cranium&#44; spinal column&#44; and diaphysis of the long bones&#46;</p><p class="elsevierStylePara">We also performed a cardiological evaluation including the following components&#58; electrocardiogram &#40;upon hospitalisation&#41; revealing a sinusal rhythm of 100bpm&#44; negative T in DI&#44; aVL&#44; and V6&#46; Echocardiogram&#58; ejection fraction &#40;EF&#41; at 60&#37;&#44; mild concentric hypertrophy in the left ventricle &#40;LV&#41; and mild mitral failure&#46;</p><p class="elsevierStylePara">With the diagnosis of IgG kappa multiple myeloma with urine elimination of free kappa in the oligosecretory range&#44; we decided on a treatment regimen including bortezomib at 1&#46;3mg&#47;m<span class="elsevierStyleSup">2</span> intravenously on days 1&#44; 4&#44; 8&#44; and 11&#44; and dexamethasone at 40mg&#47;day orally on days 1-4 and 9-12&#46;</p><p class="elsevierStylePara">Two days after receiving the first dose of chemotherapy&#44; and coinciding with a potassium level of 7&#46;5mEq&#47;l&#44; the patient suffered severe hypotension&#44; with an escape rhythm of 20bpm&#46; We administered emergency dialysis and inserted a pacemaker&#44; in spite of which we continued to detect heart rhythm abnormalities&#44; requiring a permanent pacemaker&#46; The patient continued with progressive deterioration and severe hypotension&#44; requiring the administration of noradrenaline and mechanical ventilation&#44; finally resulting in patient death two weeks after hospitalisation&#46;</p><p class="elsevierStylePara">Renal involvement in MM is common&#44; and there is a correlation between the presence and severity of renal failure and patient survival&#46;<span class="elsevierStyleSup">2</span> Cast nephropathy &#40;myeloma kidney&#41; is the most common development in patients with MM and renal dysfunction&#46;<span class="elsevierStyleSup">3</span> Protein M is not detected in approximately 3&#37; of patients with MM in the immunofixation analysis of blood and urine samples upon diagnosis&#44; considering these cases to be non-secretory MM&#59; it is rare that these patients should have cast nephropathy&#44; since there is very little light chain elimination&#46;<span class="elsevierStyleSup">4</span></p><p class="elsevierStylePara">In our case&#44; this being an oligosecretory MM &#40;with little monoclonal presence in blood and urine samples&#41;&#44; the renal histological analysis detected the presence of cast nephropathy &#40;myeloma kidney&#41;&#44; which led to the diagnosis of MM&#46; The bone marrow biopsy confirmed MM with widespread involvement&#46; The bone analysis also did not detect images indicative of osteolysis&#44; although the full-body MRI did find diffuse myeloma involvement &#40;Figure 2&#41;&#46;</p><p class="elsevierStylePara">It is also curious that in spite of the low detection of tumour mass and the previous good health of the patient &#40;with no prior cardiological incidents&#41;&#44; cardiac arrhythmias started to appear &#40;initially related to toxic hyperkalaemia possibly associated with tumour lysis due to the chemotherapy&#41;&#59; however&#44; after halting chemotherapy and intensifying the haemodialysis treatment and implanting the pacemaker &#40;temporary and permanent&#41;&#44; the cardiac arrhythmias persisted and the patient died&#46;</p><p class="elsevierStylePara">Our objective here was to communicate the case of discordance between an oligosecretory MM with a minimal monoclonal component and very extensive spread that led to patient death one week after diagnosis&#46;</p><p class="elsevierStylePara"><span class="elsevierStyleBold">Conflicts of interest</span></p><p class="elsevierStylePara">The authors have no conflicts of interest to declare&#46;</p><p class="elsevierStylePara"><a href="grande&#47;10976&#95;108&#95;25080&#95;en&#95;10976&#95;f1&#46;jpg" class="elsevierStyleCrossRefs"><img src="10976_108_25080_en_10976_f1.jpg" alt="Chest x-ray obtained upon patient hospitalisation"></img></a></p><p class="elsevierStylePara">Figure 1&#46; Chest x-ray obtained upon patient hospitalisation</p><p class="elsevierStylePara"><a href="grande&#47;10976&#95;108&#95;25081&#95;en&#95;10976&#95;f2&#46;jpg" class="elsevierStyleCrossRefs"><img src="10976_108_25081_en_10976_f2.jpg" alt="Full-body magnetic resonance&#46; Figure 1&#46; Evolution of calcium&#44; phosphorous and intact parathyroid hormone &#40;iPTH&#41; levels&#46; "></img></a></p><p class="elsevierStylePara">Figure 2&#46; Full-body magnetic resonance&#46; Figure 1&#46; Evolution of calcium&#44; phosphorous and intact parathyroid hormone &#40;iPTH&#41; levels&#46; </p>"
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