A Man With Pain in His Muscles and Bones

Camilo Jimenez, MD, Sai-Ching Jim Yeung, MDSeries Editor: Ashok Balasubramanyam, MD

Disclosures

April 02, 2003

Clinical Course and Outcome

Additional biochemical and radiologic studies were ordered to identify the cause of hypophosphatemic osteomalacia in this patient.

Serum protein electrophoresis showed a mildly elevated peak of beta-2 microglobulin, and urine protein electrophoresis showed 2 protein peaks in the beta globulin region. Both peaks were found to contain a monotypic lambda light chain protein. The quantity of Bence Jones proteinuria was 85 mg/day.

Urine measurements demonstrated normal calcium and sodium excretion, low magnesium excretion, and high phosphorus excretion.

Radiologic studies showed an enlarged spleen measuring 14 cm in diameter (Figure 4).

Abdominal CT scan with contrast showing splenomegaly with focal low density; most likely lymphomatous involvement. (See arrow.)

Biopsy of the spleen revealed a beta-cell-type lymphoma.

Treatment was initiated with calcitriol and phosphorus, and the patient was referred to the hematology service for chemotherapy. Eight months later, his serum phosphorus level is stable at about 2.9-3.0 mg/dL, the muscle and bone pains have almost disappeared, and he is able to arise from bed and walk without assistance. Current x-rays show good healing of the fractures with significant improvement in bone mass (Figure 5).

X-ray of the thoracic spine showing osteopenia improvement after 6 months of calcitriol and phosphate replacement therapy. (See arrow.)

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