Case Report
Copyright ©The Author(s) 2019. Published by Baishideng Publishing Group Inc. All rights reserved.
World J Crit Care Medl. Sep 11, 2019; 8(5): 82-86
Published online Sep 11, 2019. doi: 10.5492/wjccm.v8.i5.82
Successfully non-surgical management of flail chest as first manifestation of multiple myeloma: A case report
Rosana Muñoz-Bermúdez, Eugenia Abella, Flavio Zuccarino, Joan Ramon Masclans, Juan Nolla-Salas
Rosana Muñoz-Bermúdez, Joan Ramon Masclans, Juan Nolla-Salas, Department of Critical Care, Hospital del Mar, Barcelona 08003, Spain
Eugenia Abella, Department of Hematology, Hospital del Mar, Barcelona 08003, Spain
Flavio Zuccarino, Department of Radiology, Hospital del Mar, Barcelona 08003, Spain
Author contributions: Muñoz-Bermúdez R and Nolla-Salas J were the patient’s doctors at critical care unit and wrote the paper; Abella E was the patient’s hematologist, and contributed to manuscript drafting; Muñoz-Bermúdez R, Nolla-Salas J, and Abella E reviewed literature; Zuccarino F, radiologist, described the TC scan images and contributed to manuscript drafting; Nolla-Salas J and Masclans JR were responsible for the revision of the manuscript for important intellectual content.
Informed consent statement: All study participants, or their legal guardian, provided written consent prior to study enrollment.
Conflict-of-interest statement: The authors declare that they have no conflict of interest.
CARE Checklist (2016) statement: The authors have read the CARE Checklist, and the manuscript was prepared and revised according to the CARE Checklist (2016).
Open-Access: This article is an open-access article which was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/
Corresponding author: Rosana Muñoz-Bermúdez, MD, Staff Physician, Critical Care, Hospital del Mar, Passeig Marítim 25-29, Barcelona 08003, Spain. rmunozbermudez@parcdesalutmar.cat
Telephone: +34-93-2483000
Received: March 12, 2019
Peer-review started: March 15, 2019
First decision: June 7, 2019
Revised: July 23, 2019
Accepted: August 15, 2019
Article in press: August 16, 2019
Published online: September 11, 2019
Processing time: 184 Days and 15.5 Hours
Abstract
BACKGROUND

Multiple myeloma is a malignant neoplasm of the bone marrow characterized by neoplastic proliferation of monoclonal plasma cells with a high relationship with destructive bone disease. We present a case of a patient diagnosed with multiple myeloma and sternal fracture in association with multiple bilateral rib fractures and thoracic kyphosis, who developed a severe acute respiratory failure, thus complicating the initial presentation of multiple myeloma. We discuss the therapeutic implications of this uncommon presentation.

CASE SUMMARY

A 56-year-old man presented to Hematological Department after he had been experiencing worsening back pain over the last five months, with easy fatigability and progressive weight loss. He had no history of previous trauma. The chemical blood tests were compatible with a diagnosis of multiple myeloma. A radiographic bone survey of all major bones revealed, in addition to multiple bilateral rib fractures, a sternal fracture and compression fracture at T9, T10, T11 and L1 vertebrae. Subcutaneous fat biopsy was positive for amyloid. We started treatment with bortezomib and dexamethasone. After 24 h of treatment, he presented dyspnea secondary to flail chest. He required urgent intubation and ventilatory support being transferred to intensive care unit for further management. The patient remained connected to mechanical ventilation (positive pressure) as treatment which stabilized the thorax. A second cycle of bortezomib plus dexamethasone was started and analgesia was optimized. The condition of the patient improved, as evidenced by callus formation on successive computed tomography scans. The patient was taken off the ventilator one month later, and he was extubated successfully, being able to breathe unaided without paradoxical motion.

CONCLUSION

This case highlights the importance of combination between bortezomib and dexamethasone to induce remission of multiple myeloma and the initiation of positive airway pressure with mechanical ventilation to stabilize chest wall to solve the respiratory failure. This combined approach allowed to obtain a quick and complete resolution of the clinical situation.

Keywords: Multiple myeloma; Flail chest; Bortezomib; Mechanical ventilation; Case report

Core tip: This case report describes an adult patient with acute respiratory failure, secondary to flail chest because of a multiple myeloma. It shows how positive pressure in airway, in conjunction with an early treatment with bortezomib and dexamethasone, may lead to a successful outcome for such patients with an otherwise poor prognosis.