Hypercalcaemia, acute renal failure, anemia, multiple vertebral lytic fractures, and raindrop scull: a quintet, perfect storm

¹Department of General Practice and Family Medicine, 10^th Local Unit of Giannouli, Larisa, Greece, ²Department of Nephrology, General Hospital of Trikala, Trikala, Greece

^&Corresponding author
Nikolaos Sabanis, Department of Nephrology, General Hospital of Trikala, Trikala, Greece

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A 67-year-old female presented to the emergency department with oliguria, dyspnea, severe lower back pain, and nausea. She also reported fatigability, unintentional weight loss, and resistance to non-steroidal anti-inflammatory drugs and opioid analgesics in back pain for the previous six months. Physical examination revealed a pale, afebrile woman in acute distress with tenderness on multiple ribs and lumbar vertebrae accompanied by symptoms of compressive myelopathy. Initial laboratory assessment revealed normochromic normocytic anemia, moderate hypercalcemia, and severe renal impairment requiring hemodialysis. Over the next few days, this patient was thoroughly evaluated for an underlying malignancy, primarily, a plasma cell malignancy. Serum and urine immunofixation revealed the presence of IgA kappa monoclonal protein, anosoparesis, and Bence-Jones proteinuria while bone marrow aspiration and biopsy showed more than 80% clonal bone marrow plasma cells. Evaluation of skeleton lesions was performed with conventional plain radiographs and supplemented by low-dose computed tomography scanning. X-ray skull views disclosed multiple, well-defined lytic lesions of various sizes scattered throughout the skull, an emblematic appearance of the skull in multiple myeloma, also known as “raindrop skull” due to its similarity with the random pattern of black holes that heavy rain leaves when hitting and splashing onto a dry surface. Afterward, the patient received combined therapy with daratumumab, cyclophosphamide, bortezomib, dexamethasone, and bisphosphonate and was referred to a tertiary hospital due to the need for radiation.

Figure 1: X-ray “raindrop skull” view: multiple, well-defined lytic lesions of various sizes scattered throughout the skull in multiple myeloma