Bilateral symmetrical humeral fracture on a background of multiple myeloma and humeral capillary hemangioma

Abstract

A 59-year-old female who was managed for multiple myeloma presented with spontaneous bilateral pathologic fracture of the distal third of both humeri. She had associated renal impairment and background diabetes mellitus. Biopsy of her bone specimen from surgery shows features in keeping with capillary hemangioma. The patient was properly optimized for surgery; she was reviewed by a nephrologist and endocrinologist before surgery. Her blood investigations showed that she was anemic. She was transfused with fresh whole blood and also had renal dialysis. She subsequently was offered bilateral retrograde locked intramedullary nailing of both humeri, which was done 2 weeks apart under regional anesthesia (brachial plexus block). There was profuse intraoperative bleeding, which was controlled with bone wax and electrocautery. Biopsy of her bone specimen from surgery shows that she also has osseous capillary hemangioma rather than the provisional diagnosis of bilateral pathological fracture of the humerus following extramedullary manifestation of multiple myeloma. There have been suggestions in the literature that extra manifestations of multiple myeloma simulating hemangioma may be due to neoangiogenesis propagated by myeloma cells secreting vascular endothelial growth factor. We present a case of multiple myeloma with renal failure that presented to us with bilateral humeral fracture with a histological report of capillary hemangioma. We suggest that tumor-neoangiogenesis may be responsible for this type of manifestation. This case is a rare coincidental finding which has not been reported in literature, hence the objective of this presentation.

Keywords

• bilateral humeral fracture
• capillary hemangioma
• multiple myeloma
• neoangiogenesis
• vascular endothelial growth factor