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Department of Oral Medicine and Radiology, KLE Society’s Institute of Dental Sciences, Bangalore, Karnataka, India
ABSTRACT
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Multiple myeloma is a systemic B-cell lymphoproliferative disease that causes osteolytic lesions in the vertebra, ribs, pelvic
bone, skull and jaw. Rarely jaw lesions are seen as the first sign in multiple myeloma. This is a case report with follow
up of a 57-year-old female patient, previously treated for osteoporosis, who presented with a swelling of the jaw. On
radiographic examination, she was found to have osteolytic lesions in the mandible and skull bones. These conventional
aids led to the diagnosis of multiple myeloma thereby proving that the osteoporotic lesions were a part of the spectrum
of multiple myeloma. The patient underwent chemotherapy and is currently on follow-up. This case report emphasizes
the importance of early diagnosis of multiple myeloma in the jaw using readily available technologies and illustrates the
contribution that oral assessment can provide.
Key words: Anemia, Bence Jones protein, mandible, multiple myeloma
M
ultiple myeloma is a hematologic A 57-year-old female patient reported with a chief
malignancy which is the multifocal complaint of swelling on the right side of the jaw since
disseminated form of plasma cell myeloma; 1 month, which was spontaneous in onset. This was
its other forms being solitary plasmacytoma and followed by mobility of the lower right back tooth which
extramedullary plasmacytoma.[1] Multiple myeloma was extracted 1 week later, after which the swelling
is characterized by monoclonal proliferation of rapidly increased in size. It was painless initially and the
abnormal plasma cells.[2] Patients present with patient developed mild pain 3 weeks after its onset. No
painful, lytic bone lesions and fracture.[3] More systemic symptoms or paresthesia was present.
than 30% of the patients with multiple myeloma
develop osteolytic lesions in the jaws.[4] Prognosis Medical history revealed that the patient was apparently
of multiple myeloma is poor with the median alright until 6 months prior to her presentation, when
she developed generalized body ache, knee and back
survival of approximately 4 years.[2] Early diagnosis
pain, and had consulted a general physician for the
and management can increase overall survival. The
same. Subsequently, based on the Dual Energy X-Ray
oral cavity can provide early clues to diagnosis, as
Absorptiometry (DEXA) Bone Densitometry, she
reported in this paper.
was diagnosed with osteoporosis and was prescribed
Access this article online Risedronate Sodium 35 mg for 12 weeks, which she
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took for 7 weeks only. The patient was also prescribed
Website: calcium tablets.
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Extraorally, there was a solitary diffuse swelling over the
DOI: right lower third of the face [Figure 1]. It was firm with no
10.4103/0972-1363.155664
local rise in temperature or tenderness. Teeth numbers
46 and 47 were missing and the sockets were healed. A
Address for correspondence: Dr. Shubhasini A. Raghavan, Department of Oral Medicine and Radiology, KLE Society’s Institute
of Dental Sciences, No. 20, Yeshwanthpur Suburb, Tumkur Road, Bangalore - 560 022, Karnataka, India.
E-mail: subhashiniar@gmail.com
Received: 23-08-2014 Accepted: 26-03-2015 Published: 22-04-2015
454 Journal of Indian Academy of Oral Medicine & Radiology | Oct-Dec 2014 | Vol 26 | Issue 4
Raghavan SA et al.: Multiple myeloma of jaw
non-tender buccal vestibular obliteration with cortical a differential diagnosis of Langerhans cell histiocytosis,
expansion was observed. A provisional diagnosis of metastatic carcinoma and hyperparathyroidism.
residual cyst was made, with a differential diagnosis
of ameloblastoma and keratocystic odonogenic tumor. Hematological investigations revealed normocytic
hypochromic anemia with decreased Hb (7.5 gms/dl),
Panoramic radiograph [Figure 2] revealed a large raised ESR (75 mm/hr), and raised serum calcium level
irregular osteolytic lesion in the right body of the (12.05 mg/dl). Serum protein electrophoresis showed
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mandible extending from 45 to 48 region; superoinferiorly monoclonal increase in the M protein in the gamma-
from the alveolar crest to inferior cortex. The lesion had region and a positive Bence Jones protein test. Serum
a well-defined margin without sclerosis and a totally urea (71 mg/dl), creatinine (6.6 mg/dl) and uric acid
radiolucent internal structure. There was loss of lamina (7.24 mg/dl) were raised. Ultrasonography revealed
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dura at the apex of 44 and 45, as well as discontinuity of bilateral renal parenchymal disease. Other advanced
the lower border of mandible, suggestive of a pathologic radiographic investigations were not warranted as
fracture. the conventional images provided pathognomonic
information.
To evaluate the inferior cortex and buccal cortical
expansion, a postero-anterior (PA) view [Figure 3] and Incisional biopsy of the right lower alveolus was carried
lateral skull view were carried out. The images showed out which revealed sheets of malignant plasma cells
multiple punched-out radiolucencies involving the [Figure 4]. Serum and urine protein electrophoresis
skull bones, facial bones and mandible. Considering the revealed a monoclonal spike in the gamma region. Bone
radiographic pattern and age of the patient, a radiographic marrow biopsy and aspiration revealed sheets of more
diagnosis of multiple myeloma was reached upon, with than 70% malignant plasma cells and plasmablasts,
thereby, confirming the diagnosis of multiple myeloma.
Journal of Indian Academy of Oral Medicine & Radiology | Oct-Dec 2014 | Vol 26 | Issue 4 455
Raghavan SA et al.: Multiple myeloma of jaw
dexamethasone 40 mg once a week for 12 weeks. The punched-out lesions in the skull. She also presented with
patient has completed this treatment and is doing well anemia, raised ESR, raised serum calcium and a positive
and remains under follow-up [Figure 5]. Surgical and Bence Jones protein test.
prosthetic management of the jaw lesions have been
planned. Administration of Dexamethasone or Prednisone, either
alone or in combination with Thalidomide, remains
a corner stone of multiple myeloma therapy. This is
Discussion
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456 Journal of Indian Academy of Oral Medicine & Radiology | Oct-Dec 2014 | Vol 26 | Issue 4
Raghavan SA et al.: Multiple myeloma of jaw
9. Sachidanandan MK, Manoharan S, Rajaram K, Palanisamy MK, 12. Munshi NC, Longo DL, Anderson KC. Plasma Cell Disorders.
Soundarapandi P, Elumalai C. Multiple myeloma: Report of In: Longo DL, Fauci AS, Kasper DL, Hauser SL, Jameson JL,
a very rare case and review. J Indian Acad Oral Med Radiol Loscalzo J, editors. Harrison’s Principles of Internal Medicine.
2012;24:91-4. 18th ed. Vol. 1. USA: Mc Graw-Hill Co.; 2012. p. 936-44.
10. Pratt G. Molecular aspects of multiple myeloma. Mol Pathol
2002;55:273-83. How to cite this article: Raghavan SA, Nagaraj PB, Ramaswamy B,
11. O’Connell TX, Horita TJ, Kasravi B. Understanding and Nayak DS. Multiple myeloma of the jaw: A case report. J Indian Acad
interpreting serum protein electrophoresis. Am Fam Physician Oral Med Radiol 2014;26:454-7.
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