Eventually, a bone marrow biopsy was performed. The bone marrow aspirate showed 90% hypercellular marrow with greater than 50% of marrow cells displaying very immature, undifferentiated IDO inhibitor plasma cells. Findings were consistent with multiple myeloma. Subsequent therapy was modified to include dexamethasone and bortezomib. The patient’s dyspnea and hypoxia improved to allow successful extubation with home oxygen support. Inhibitors,research,lifescience,medical Outpatient hemodialysis was continued with improvement in BUN and creatinine, but the patient remained dialysis dependent. Commentary This case report highlights pulmonary renal syndrome manifesting as the initial presentation of multiple myeloma. Pulmonary renal syndromes are typically caused by systemic vasculitis

and autoimmune disorders such as microscopic polyangiitis, Wegener’s granulomatosis, Goodpasture syndrome, and systemic lupus erythematosus. The aforementioned rheumotalogical entities are commonly associated with positive autoantibodies on serologic Inhibitors,research,lifescience,medical tests, all of which were

negative in this patient. However, antibody negative tests do not definitively rule out a vasculitic or autoimmunie disorder.1 Futhermore, Inhibitors,research,lifescience,medical this patient’s clinical presentation of pulmonary hemorrhage and renal failure was strikingly convincing for an antibody negative systemic vasculitis, resulting in his empiric treatment with steroids and cyclophosphamide and strong consideration of plasma exchange. However, failure to respond prompted the search for an alternative diagnosis. Pulmonary hemorrhage and acute renal failure as the initial presentation of multiple myeloma has been reported in only one other case report in 2010. In the initial case report, the patient Inhibitors,research,lifescience,medical was treated with plasma exchange, steroids, and melphalan, resulting in improvement of symptoms.2 Our patient did not receive plasma exchange. The use of plasmapheresis to improve renal function is controversial, and multiple Inhibitors,research,lifescience,medical studies

have failed to establish general consensus. The largest systematic review in 2010 showed no significant improvement in renal failure or morbidity and mortality with plasmapheresis, although smaller studies showing restoration of normal renal function have been reported.3, 4, 5 Thus, it is unclear if plasmapheresis Adenosine was the cause for improvement in renal function or if function was related to severity of underlying multiple myeloma or other still unknown variables. Although the antibiotic therapy with TSM could be implicated in the development of renal failure, the failure of the creatinine to return to baseline after discontinuation and the presence of casts suggest myeloma kidney since, in a recent study, these features were not associated with cases of TSM-induced renal injury.6 Multiple myeloma involves bone marrow invasion by plasma cell tumor. It is associated with monoclonal gammopathy and classic findings of bone pain from the infiltrating tumor, pathological fractures, fatigue, and weight loss.