Photoclinic

A 55-year-old previously healthy man was admitted with a diagnosis of pneumonia, and successfully managed with intravenous antibiotics. On admission day, laboratory evaluations were noted: white blood cell (WBC), 12500/μL, hemoglobin (Hgb), 8.3 g/dL, platelet (PLT), 164000/μL, C-reactive protein (CRP), 33 mg/L, erythrocyte sedimentation rate (ESR), 110 mm/h, and calcium serum (Ca), 12.9 mg/dL. Despite the improvement of signs and symptoms, ESR, Hgb and Ca levels were 118 mm/h, 8.1 g/dL, and 13 mg/dL respectively. Because of persistent anemia, hypercalcemia, and elevated ESR, the patient underwent serum and urine protein electrophoresis and immunotyping (Figure 1). Serum B2 microglobulin was 4.3 IU/mL. Bone marrow aspiration (Figure 2) and biopsy were performed.Metastatic cells of a primary lung cancer were found scattered to alveoli, epicardium, pericardial sac, lymph nodes, and pulmonary interstitium (“carcinomatous lymphangitis”). There was neither remarkable pericardial or pleural effusion, nor evident thromboembolism.