Category: Brief Report and Case Report

What can hide a simple backache? A case report

Valeria Clemente MD - PhD, Beniamino Susi MD
Department of Emergency Medicine of Polyclinic Tor Vergata Rome


Low back pain is one of the most common presentations to the Emergency Department, with an incidence of 5% and a peak of prevalence between 35 and 55 years. For not all people it is possible to identify a specific cause. In most cases it is a benign disease, that resolves within 6 weeks, only in 1% of cases have a well understood pathological cause such as fracture, infection or malignancy (1). Multiple myeloma (MM) is a malignancy affecting the elderly, with a median age of 70 years, rarely occurs in younger than 40 years (up to 2% of all cases), in which however prognosis is better. Early diagnosis of MM can be difficult, because many patients are asymptomatic until the advanced stage of disease (2).

Case report

We report the case of a 40-year old man, who came to our observation in the Emergency Department, for the appearance of atraumatic right back pain, from one month, for which he was performing acupuncture cycle without benefits. The patient was in good health. Laboratory exams showed only normochromic normocitics anemia (haemoglobin 8,4 gr/dl), because the other required exams could not be assessed, due to the tendence to agglutinate quickly. A recent skeletal muscle ultrasound showed bone discontinuity of the last right ribs and a lumbosacral magnetic resonance was normal. The hematologist carried out peripheral blood smear, which appeared normal and in the suspicion of paraprotinemia, all the exams with cold agglutinins, cryoglobulins and protein eletcrophoresis dosages have been repeated. The protidogramma showed increase in total proteins (11,3 gr/dl) with a monoclonal peak in the gamma area (6 gr/dl) (Figure 1). The total body CT highlighted fracture of the twelfth dorsal vertebra and rarefaction of the sternum, humerus, first lumbar vertebra and scapular girdle. The following day patient was hospitalized to continue the treatment and investigation of the case.


Low back pain is a very common condition, particularly in developed countries from children to the elderly population. It is a major cause of medical expenses, work absenteeism and disability. In most cases, it is a benign pathology with spontaneous resolution, but which can hide diagnostic pitfalls. In 1% of cases it can be the spy of a malignancy or metastasis. Therefore the differential diagnosis with respect to red flags such us tumors, fractures, infections, inflammatory low back pain and cauda equina syndrome is mandatory. The warning signs in the suspicion of a tumor to be taken into account are weight loss, previous tumors, age over 50 years, no improvement of pain after therapy, night pain and at rest (3). Multiple myeloma is a hematological malignancy with an incidence of 10,000 deaths per year in the United States and Europe, which can begin with low back pain at an advanced stage. Therefore, early identification of disease progression is important for prognosis in these patients. The advent of novel drugs has significantly improved response rates and progression-free survival (4).


1) What low back pain is and why we need to pay attention. Hartvigsen J, Hancock MJ, Congested A, et al. Lancet 2018 Mar 20 doi: 10.1016/S0140-6736(18)30480-X.  2) Characteristics and outcomes of patients with multiple myeloma aged 21–40 years versus 41–60 years: a multi-institutional case-control study. Artur Jurczyszyn, Hareth Nahi, Irit Avivi, et al. British Journal of Haematology, 2016, 175, 884–891.3) Red flag presented in current low back pain guidelines: a review. Verhagen AP, Downie A. Popal N et al. Eur Spine J. 2016 Sep 25 (9): 2788-802 dos: 10.10077s00586-016-4684-0. Epud 2016 Jul 4.4) Prognostic value of circulating plasma cells in patients with multiple myeloma: A meta- analysis. Jia Li, Ningning Wang, Nahom Tesfaluul, Xiaojuan Gao, Shuai Liu,  Baohong Yue. PLoS One. 2017 Jul 13;12(7): e0181447. doi: 10.1371/journal.pone.0181447. 





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