When the Pleura Speaks Plasma: An Unusual Manifestation of Relapsed Multiple Myeloma

paving pattern (ground-glass opacities with septal thickening), predominantly in the right upper lobe (Figs 2 and 3).These findings suggested fibrotic interstitial lung disease with a possible superadded acute component (infection, edema, or acute exacerbation).Thoracentesis yielded a reddish-yellow pleural fluid.Biochemical analysis revealed a protein level of 2.48 gm/dL, glucose of 52.2 mg/dL, and adenosine deaminase (ADA) of 7.3 U/L.Pleural fluid examination showed a total leukocyte count of approximately 800 cells/mm 3 , with lymphocyte predominance (84%) and a smaller proportion of polymorphs (8%).Red blood cells were present in fair numbers, along with occasional mesothelial cells.Microbiological evaluation demonstrated no IntroductIonMultiple myeloma is a hematologic malignancy characterized by clonal proliferation of plasma cells, monoclonal protein production, and end-organ damage.Pleural effusion in multiple myeloma is uncommon and is usually secondary to conditions such as congestive heart failure, renal insufficiency, hypoalbuminemia, or infections.True myelomatous pleural effusion (MPE), defined by the presence of malignant plasma cells in pleural fluid, is exceedingly rare and accounts for less than 1% of cases.It is often associated with aggressive disease biology, particularly plasmablastic morphology, and carries a poor prognosis.Early recognition is crucial for timely management and prognostication. case descrIptIonStudy in Sanjivini Super Speciality Hospital, Lucknow, Uttar Pradesh, a 64-year-old female, a known case of multiple myeloma diagnosed 4 years prior, presented with complaints of progressive breathlessness, nonproductive cough, and diffuse chest pain for one month.She had previously received cyclophosphamide-based immunosuppressive therapy for 2 years, following which treatment was discontinued.On examination, the patient was dyspneic with reduced bilateral chest expansion.Auscultation revealed decreased breath sounds over the bilateral lower lung fields with stony dullness on percussion, suggestive of the bilateral effusion. ImagIngChest radiography revealed bilateral pleural ef fusion (Fig. 1).Contrast-enhanced computed tomography (CT) thorax demonstrated moderate bilateral pleural effusion with passive atelectasis.Diffuse interstitial lung disease with fibrotic changes and subpleural honeycombing (right > left) superadded a crazy-