case_images: PMC9899953_01
case_images: Serum protein electrophoresis at the time of diagnosis showing a narrow
  monoclonal spike in the gamma-globulin region. Albumin (Alb) 17.5 g/l
  (reference interval [RI] 44.5-62.3), 21.4% (RI 25.0-39.0%); alpha 1
  globulins (alpha1) 1.7 g/l (RI 2.2-7.6), 2.1% (RI 2.0-5.0%); alpha 2 globulins
  (alpha2) 5.4 g/l (RI 5.7-19.9), 6.6% (RI 8.0-11.0%); beta 1 globulins (beta1)
  8.6 g/l (RI 2.8-11.3), 10.5% (RI 3.0-5.0%); beta 2 globulins (beta2) 2.7 g/l
  (RI 3.1-11.7), 3.3% (RI 3.0-6.0%); gamma globulins (gamma) 64.1 g/l (RI
  5.8-23.0), 78.2% (RI 12.0-32.0%). Agarose gel electrophoresis Hydrasys 2
  Scan (Sebia)
case_images: 10.1177_20551169221134094-fig1.jpg
case_images: PMC9899953_01_10.1177_20551169221134094-fig1.jpg
case_images: fig1-20551169221134094
case_images: Serum protein electrophoresis (SPE) revealed a monoclonal gammopathy with a gamma-globulinaemia of 64.1 g/l (RI 5.8-23.0) (Figure 1).
case_images: Photomicrograph of pleural effusion. Plasma cells show the following atypia:
  anisocytosis, anisokaryosis (red arrows), binucleation (green arrow) and
  macrokaryosis (yellow arrow). Some plasma cells are immature (blue arrow).
  Erythrophagocytosis was seen in many macrophages (black arrows).
  May-Grunwald-Giemsa stain. Scale bar 20 microm
case_images: 10.1177_20551169221134094-fig2.jpg
case_images: PMC9899953_01_10.1177_20551169221134094-fig2.jpg
case_images: fig2-20551169221134094
case_images: Cytological examination showed plasma cells, representing up to 40% of nucleated cells, with marked atypia, binucleations, anisocytosis, anisokaryosis, macrokaryosis and mitotic figures (Figure 2).
case_images: Cytological analysis of bone marrow aspiration. (a) Photomicrograph. Note the
  marked hypercellular bone marrow due to plasma cells invasion and the
  reduced erythroid lineage. (b) Photomicrograph. Plasma cells with
  anisocytosis, anisokaryosis (red arrows), binucleation (green arrow),
  macrokaryosis (yellow arrow) and mitotic figures (black arrow) are observed.
  May-Grunwald-Giemsa stain. Scale bars: (a) 100 microm and (b) 20 microm
case_images: 10.1177_20551169221134094-fig3.jpg
case_images: PMC9899953_01_10.1177_20551169221134094-fig3.jpg
case_images: fig3-20551169221134094
case_images: Binucleation, anisocytosis, anisokaryosis and macrokaryosis were prominent among these plasma cells (Figure 3).
case_images: (a) Thoracic ventrodorsal projection radiograph. A pathological fracture of
  the fifth rib (blue arrow) and pleural effusion are seen (yellow arrow). (b)
  Right thoracic lateral projection radiograph. Pleural effusion is present
  (yellow arrows). (c) Left lateral projection radiograph of thoracic spine:
  numerous circular bone lytic lesions are observed on spinous processes (red
  arrows) and probably healed rib fractures (blue arrows). (d) Ventrodorsal
  projection radiograph of the pelvis: osteolytic lesions are observed,
  involving proximal extremities of both femurs (red arrows)
case_images: 10.1177_20551169221134094-fig4.jpg
case_images: PMC9899953_01_10.1177_20551169221134094-fig4.jpg
case_images: fig4-20551169221134094
case_images: Thoracic radiographs performed after thoracocentesis showed pathological rib fractures, persistent pleural effusion and lung atelectasis, with no evidence of mass lesion (Figure 4a,b). Spine and pelvis radiographs revealed multiple lytic bone lesions consistent with bone geodes (Figure 4c,d).