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Shortness of breath and diffuse chest pain

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Q1: What is the diagnosis?

The diagnosis is flail chest with acute respiratory failure. As the patient has not suffered any trauma it would be considered as spontaneous.

Q2: What is the primary disease?

The underlying disease after considering all the parameters is multiple myeloma stage IIIB.

Q3: What are the causes of flail chest?

Flail chest denotes a condition in which the chest deforms markedly during quiet breathing and is produced by double fractures of three or more contiguous ribs or combined sternal and rib fractures.1 Flail chest occurs in 20% of patients with blunt chest trauma and is usually sustained by falls from high places, in automobile accidents, or during cardiac resuscitation and the accompanying mortality may be as high as 30%–40%.2Flail chest may also occur with pathological fractures of the ribs with trivial trauma. However, as in the case presented here, if the diagnosis of multiple myeloma is delayed, spontaneous fractures of multiple ribs can cause flail chest and the patient can present with acute respiratory failure.

Q4: What are the treatment options?

The treatment options are treatment of multiple myeloma with chemotherapy and stabilisation of the chest wall. Many methods have been improvised to stabilise the chest wall. At the present time endotracheal intubation with the use of a volume respirator has largely supplanted all other methods.3 This approach maintains ventilation at physiological levels and stabilises the thoracic wall in an expanded position that tends to minimise late chest wall collapse and later disability. Intermittent mandatory ventilation at a rate of 10–16/min associated with moderate levels of positive end expiratory pressure or continuous positive airway pressure is usually used. Occasionally controlled ventilation with tidal volumes from 1000–2000 ml with added dead space may be used. Serial blood gas determinations dictate both the need for respiratory assistance and the time to terminate or wean a patient from the ventilator. Usually 5–10 days is required before adequate stability of the chest wall is restored. Longer periods may be required in the elderly.

Discussion

Multiple myeloma is a relatively indolent neoplasm in which the terminally differentiated B lymphocytes, known as plasma cells, accumulate and become the distinctive feature of the tumour. The clinical spectrum varies widely ranging from the incidental discovery of a monoclonal peak on plasma protein electrophoresis to widespread skeletal involvement and incapacitating bone pain.4 5Bone pain is the most common symptom of multiple myeloma.1 6 The bone lesions of myeloma are caused by proliferation of tumour cells and activation of osteoclasts which respond to osteoclast activation factors produced by myeloma cells. Punched out lytic lesions without associated osteoblastic changes are characteristic of myeloma. The vertebrae, skull, thoracic cage, pelvis, and proximal humeri and femurs are the usual sites of involvement.6 Pathological fractures especially of the vertebrae are not uncommon and may lead to spinal cord compression. It is therefore not surprising that this neoplasm may be misdiagnosed and in many cases long periods elapse before the error is corrected. It follows that the diagnosis rests to a large extent on having a high index of suspicion and then by doing relevant investigations without delay.7

Final diagnosis

Multiple myeloma with spontaneous flail chest and acute respiratory failure.

Learning points

  • Multiple myeloma should be suspected in patients with longstanding bone pain

  • The clinical spectrum of multiple myeloma varies widely, ranging from the incidental discovery of a monoclonal peak on plasma protein electrophoresis to widespread skeletal involvement and incapacitating bone pain

  • Diagnosis rests to a large extent on having a high index of suspicion

  • Flail chest is a rare complication of myeloma

References

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