Fulminating Hepatic Necrosis in a Patient with Multiple Myeloma Treated with Urethane

Mrs. D. H. (No. A-53-969), a 62 year old, married, white woman was admitted to hospital in August of 1953 for investigation of low back pain which radiated into the right hip and which was of six weeks’ duration. Six months prior to admission she had had cervical pain of sudden onset which radiated into her shoulders and was aggravated by movement. This pain lasted three months and then gradually receded, leaving residual paraesthesias in her hands. In these six months her weight dropped from 175 to 123 pounds. She had noticed drooping of her right eyelid for one year and a gradually enlarging lump on the back of her head for seven months, but as both were painless, she had not sought mnedical attention. Physical examination revealed ptosis of the right eyelid with an associated small right pupil. There was a soft, fluctuant, non-tender swelling which measured 8 x 10 cm. in the right parieto-occipital region. Examination of the cardiovascular and respiratory systems showed them to be normal. No masses were palpated in the abdomen. There was tenderness over the fifth cervical vertebra and over the tenth ribs. All peripheral joints moved painlessly through a normal range. Hoffman’s sign was present bilaterally and the plamitar responses were extensor. Pain sensation was diminished in the left leg and vibration sense was absent in the right foot. A Rumpel-Leeds’ test was positive. Laboratory investigation revealed a hemoglobin of 68 per cent (9.9 Gm.) and a red i)lood cell count of 3,100,000 per cu. mm. The red cell morphology was fairly regular although there was marked rouleau formation. The erythrocyte sedimentatiomi rate 26 mnm. per hour, Westergren. The white cell count was 7,350 per cu.mni. with a normal differential. The coagulation factors were normal. The sternal marrow showed 8.7 per cent plas nia cells, 51 per cent proplasma cells and 1.3 per cent plasmoblasts. The serum albumin was 3 Gm. per cent and serum globulin 10.2 Gm. per cent. The liver function tests were otherwise normal. The N.P.N. was 39 mg per cent. The serum calcium was 9.4 mg. per cent. The urine specific gravity ranged between 1.015 and 1.022. The average pmoteiti excretion was 150 mg per cent (4 plus). The sediment contained 1 plus white ibood cells :tnd occasional red blood cells. Bence-Jones protein was repeatedly present. A skeletal radiological survey showed generalized demineralizatiomi of hone, with a compression fracture of the fifth cervical vertebra, such that the vertel)ral hody was cxtruded posteriorly. There were several punched out areas in the ribs, humeri and skull. A soft tissue tumor containing calcium was seen eroding the right parietal nad occipital bones.