Bone marrow infiltration as the initial presentation of gastric signet ring cell adenocarcinoma

A 52-year-old African American man, with a history of sickle cell trait, alpha-thalassemia, gynecomastia and nephrolithiasis presented to the emergency department of an urban, tertiary-care medical center with worsening back pain. The patient stated that 3 weeks prior he experienced minor trauma while driving a bus and has since had severe pain in his lumbar region that was unresponsive to over-the-counter analgesics. The patient denied further symptoms, including weight loss, fever, night sweats, abdominal pain, dyspepsia, nausea, vomiting, hematochezia, and melena. Of note, the patient had a family history significant for a first-degree relative with multiple myeloma (MM) and another with breast cancer. On physical exam, the patient was tender to palpation in the lower thoracic and lumbar spine. The patient had no saddle anesthesia or focal neurologic deficits, and the abdominal exam was benign. Initial laboratory evaluation revealed a white blood cell (WBC) count of 13.1 K/UL, a hemoglobin of 10.2 G/DL with an MCV of 65, and a platelet count of 184 K/UL. The creatinine was elevated to 1.47 mg/DL and the serum calcium was 10.8 mg/DL. Liver function tests (LFT) were significant for an alkaline phosphatase of 1,372 U/L, while other LFTs were normal. Computed tomography imaging of the chest, abdomen, and pelvis revealed a compression fracture of the L1 vertebral body as well as lytic lucencies in the T5 and T9 vertebral bodies (Figure 1), prominent lymph nodes in the right upper quadrant, and a 1.8 cm hypoattenuating lesion in the left lobe of the thyroid gland