561 - Newly Diagnosed Multiple Myeloma Presenting as Lumbar Radiculitis: A Case Report

Case Diagnosis: A 59-year-old male presented to clinic with 1 year of lower back pain with intermittent radiation down the posterolateral right leg. He had a suboptimal response to physical therapy, acetaminophen, and naproxen. MRI of the lumbar spine was ordered for planning for a right transforaminal epidural steroid injection.

Case Description: MRI revealed pathologic compression fractures at T12/L2, and diffuse marrow replacement throughout the spine, consistent with malignancy. On follow-up, the incidental findings were discussed using the SPIKES protocol. A multiple myeloma workup was positive, and a referral to oncology was made. He ultimately presented to the emergency room with a soft tissue abscess after cutting his left hand while washing dishes. After an incision and drainage with orthopedics, he was admitted to the myeloma service for malignant hypercalcemia/cellulitis and was treated with IV fluids, denosumab, calcitonin, and vancomycin. He was subsequently treated with daratumumab, cyclophosphamide, dexamethasone, underwent a bone marrow biopsy, and ultimately was discharged home. On follow-up in myeloma clinic, he was determined to have an Eastern Cooperative Oncology Group performance status of 1, and Karnofsky Performance Status scale of 80. He was considered a transplant-eligible patient, who would benefit from quadruple therapy of daratumumab, lenalidomide, bortezomib, and dexamethasone.

Discussions: Multiple myeloma is the second most common hematologic malignancy in adults. The presenting findings of multiple myeloma can include lumbar radicular back pain, and 58% of patients may suffer from back pain in the two years preceding their diagnosis. A compilation of six cohort studies assessing low back pain in 5883 patients showed that the prevalence of spinal malignancy ranges from 0 – 0.66%.

Conclusions: In the outpatient setting, physiatrists may be one of the first clinicians to evaluate and manage undiagnosed cancer. In this case, we had successful coordination of care to ensure prompt treatment of the patient’s newly diagnosed malignancy.