Concurrent Challenges: Multiple Myeloma and Cardiac Amyloidosis

We report a case of 56-year-old male with known case of Hypertension and Hypothyroidism presented with complaints of generalised weakness and weight loss since 8 months (approx. 40kg), tightening in and around the mouth and hoarseness of voice with dysphagia since 6 months, swelling in feet since 3 months, cough and constipation on and off since one month. The laboratory results indicated that the serum calcium (S.Ca2+) level was 14.1 mg/dl and the ionized calcium (Ca2+) level was 1.62 mmol/l. Immunoglobulins were low {IgA- 17 mg/dl (50-410 mg/dl), IgG- 386 mg/dl (650-1500 mg/dl), IgM- 20 mg/dl (60-280 mg/dl); Immunofixation electrophoresis (IFE) revealed positive result for lambda free light chain (Figure 1) and further quantitative value lambda free light chain was high (Lambda free - 2054.89 mg/l). Whole Body FDG PET Scan revealed non-FDG avid lytic lesions at multiple bone sites. In view of suspicion of Multiple Myeloma, bone marrow aspiration and trephine biopsy were done which confirmed the diagnosis of Multiple Myeloma. ECG showed low voltage QRS complexes and 2D echo revealed- Global LVEF 55-60%, Dilated LA, concentric LVH with altered myocardial echotexture, no RWMA, Grade II diastolic dysfunction present (raised LVEDP), RVSP-39mmhg (moderate PAH), findings S/O- cardiac amyloid; which was later confirmed with Cardiac MRI. Abdominal fat pad biopsy revealed area of necrosis but negative for congo red stain (amyloidosis). The patient underwent VCD (bortezomib; cyclophosphamide; dexamethasone) chemotherapy with Daratumumab. By the time of publication, the patient had received autologous stem cell transplantation and after 10 courses of VCD with Daratumumab, repeat bone marrow aspiration and histo-biopsy revealed complete remission of myeloma. The uncommon Multiple Myeloma complication in this clinical case was associated with restricted cardiomyopathy as a result of secondary cardiac amyloidosis. This is true for both Multiple Myeloma and cardiac amyloidosis. When one of these diagnoses is initially established, more investigation should be done to rule out the other illness, keeping in mind the necessity of meeting standard diagnostic criteria and the challenge of conducting an effective diagnostic workup in occasionally complex clinical situations.