1. INTRODUCTION Multiple Myeloma presenting with Bilateral Ankle Pain and complicated by Streptococcal Meningitis and Pneumocystis Carinii Pneumonia. BONE MARROW BIOPSY L. Dunphy 1, N. Singh 2, C. Danbury 3. Department of Anaesthesia and Intensive Care Medicine. The Royal Berkshire Hospital. CASE PRESENTATION REFERENCES INVESTIGATIONS Due to her IgG kappa paraprotein, kappa light chain of 4620 and kappa:lambda ratio she was diagnosed with probable plasma cell myeloma. A vascath was inserted via a femoral approach and she commenced renal replacement therapy, with an improved renal function noted. She required inotropic support with noradrenaline to maintain a MAP> 65. A chest radiograph confirmed bilateral consolidation and she commenced treatment with IV amoxicillin. Fig.2. Radiographs of her feet and ankles showed no bony injury. Figs.3,4. Three days post admission, she developed a severe headache and confusion, GCS 10/15, requiring intubation and ventilation. A CT Head showed no evidence of acute intra-cranial pathology. Fig. 5. She commenced nasogastric tube feeding. A lumbar puncture was performed. Macroscopically, clear yellow fluid was observed. Her CSF indicated a dense neutrophilic infiltrate, with approximately 10% of cells consisting of monocytes and foamy macrophages; 90% were polymorphs. Her glucose was low [<1.1] and her protein was high [>6]. There was no evidence of myelomatous meningitis or fungal spores. Enterovirus was not detected and there was no bacterial growth after 48 hours. Her pneumococcal antigen was positive for Streptococcal Pneumoniae. She commenced treatment with IV ceftriaxone, acyclovir and fluconazole. MRI Spine showed no evidence of malignancy. Fig.6. INVESTIGATIONS OUTCOME SKELETAL SURVEY  Siegal RL, Miller KD, Jemal A. Cancer Statistics 2016. CA Cancer J Clin 2016, 66:7.  Hutchison CA, Batuman V, Behrens J et al. The Pathogenesis and diagnosis of acute kidney injury in multiple myeloma. Nat Rev Nephrol 2012:8:43. The first case of multiple myeloma was described by Dr. Samuel Solly in 1884. The term “Kahler’s disease” was used to describe myeloma following a report by Fig.1. Prof. Otto Kahler of Prague. Fig.1. Multiple myeloma, a plasma cell malignancy is characterized by the neoplastic proliferation of plasma cells producing a mono- clonal immunoglobulin, accounts for 1% of all cancers, but 12% of haematological malignancies. The plasma cells proliferate in the bone marrow often resulting in extensive skeletal destruction, with osteolytic lesions, osteopenia and/or pathological fractures. We report the case of a 64 year old female admitted to the Department of Intensive Care Medicine at the Royal Berkshire Hospital with end organ damage attributable to a suspected underlying plasma cell disorder. She presented to the Emergency Department at Wexham Park Hospital with rapid onset, painful distal symmetrical limb weakness leading to impaired mobility. Respiratory, cardiovascular and abdominal examination were normal.Neurological exam confirmed decreased power in both legs [4/5]. There was no sensory level and her reflexes were normal. There was no bladder or bowel dysfunction. Biochemistry revealed an abnormal renal function: urea 41.1 mml/l, creatinine 966 umol/l and eGFR 4ml/min. Furthermore, a low haemoglobin [79g/l] with a MCV of 97.8fl was observed. She had an elevated white cell count [11.50x10] and a raised CRP 235.3 mg/l. Table.1. A urine dip was negative for leukocytes, but positive for blood 200+++ and protein 300+++. Hb 79g/l Urea 41.1 WCC 11.5 Creatinine 966 Na 127 eGFR 4 K+ 4.3 B12 1159 Albumin 28 Folate 6 Fig.2. A chest radiograph revealed bilateral consolidation. Fig. 3,4. No bony injury evident. Fig. 5. There was no evidence of haemorrhage, acute infarction or space occupying lesion. Fig.6. There was no marrow deposit or infiltration. As her clotting parameters were normal, a bone marrow aspirate and biopsy were performed from the right posterior superior iliac spine. Two bony cores measuring 31mm were yielded by trephine biopsy and sections were examined at three levels. A significant interstitial plasmacytosis throughout the length of the biopsies was evident. Congo red was negative for amyloid. Immuno-histochemistry confirmed that the infiltrate was CD18 positive and kappa light chain restricted with a tumour burden of 60%. The features were consistent with plasma cell myeloma, ICD-0 code. Fig. 7,8,9. Fig.7. At low power, the abnormal plasma cells of multiple myeloma fill the bone marrow. Fig.8. At medium power, poorly differentiated plasma cells are evident. Fig. 9. A smear of bone marrow aspirate showing numerous plasma cells with eccentric nuclei and a perinuclear halo of clearer cytoplasm. She was reviewed by the Haematologists and commenced treatment with bortezomib [velcade]. Her beta glucan was negative but her NBBAL isolated Pneumocystis Carinii Pneumonia and she commenced treatment with co- trimoxazole. She required a percutaneous tracheostomy. A skeletal survey was performed and no focal myeloma deposits were observed. Figs. 10, 11, 12, 13. Neurology review confirmed preserved knee jerks and absent ankle reflexes. Impaired vibration below her knees and temperature below her upper calves was noted. The diagnosis was of confluent, painful mononeuritis multiplex affecting her lower limbs, likely giving rise to axonal injury, a pattern typically seen in vasculitic neuropathies. It was thought likely that the underlying pathology was a microangiopathy. Fig. 10. Skeletal Survey. Fig.11 Fig.12. Fig.13.