Endolymphatic mass in a patient with undiagnosed multiple myeloma

Case reportA 68-year-old Caucasian male with a history of coronary artery disease, a recent clavicular fracture, and vertigo sought emergency evaluation for recent episodes of vertiginous attacks with imbalance.Initial episodes of vertigo were well managed with triamterene and hydrochlorothiazide (HCTZ) until several weeks after presentation.He noted that the attacks were worse with position change and nearly caused him to fall on multiple occasions.He also acknowledged hyperacusis in the left ear.On physical examination, he had a positive Romberg's sign and leaned to the left with tandem gait.His hearing with the fi nger rub test was louder on the left than the right.An MRI brain with and without contrast demonstrated an enhancing mass in the left temporal bone in the area of the endolymphatic sac, which extended inferiorly towards the jugular foramen (Figure 1).The main item on the differential was an endolymphatic sac tumor due to the location, high T1 signal, and further enhancement with contrast (Figure 1a-d).Imaging characteristics were also consistent with other true endolymphatic sac tumors .Less likely alternatives included metastasis, glomus tumor, cholesteatoma, or cholesterol granuloma.Imaging of the chest, abdomen and pelvis were performed as part of the work up.These demonstrated numerous lytic lesions including pathological rib and clavicular fractures, as well as a 8.4×6.2 cm soft tissue mass involving the AbstractIntracranial lesions located within the region of the endolymphatic sac are typically associated with locally invasive disease rather than metastasis.In this case, we report on a 68-year-old man with no oncological history presenting with vertigo and hyperacusis, who was found to have a solitary enhancing mass of the left temporal bone.Subsequent systemic imaging raised concern for a metastatic lesion, and the patient was ultimately diagnosed with multiple myeloma.Multiple myeloma rarely presents with symptomatology consistent with intracranial pathology.This report highlights the importance of surveillance for metastatic disease even when primary lesions are suspected.