PMC10287112_01
(A) Peripheral blood film showing multiple rouleaux, morphologically normal WBC, and platelets. May-Giemsa, x100 objective. (B) Bone marrow aspirate with numerous plasma cells, comprising over 90% of bone marrow cells, reduced erythropoiesis, granulopoiesis, and thrombopoiesis. Plasma cells contain Dutcher bodies and Russell bodies. H&E, x200 objective. (C) Strong expression of CD138 on plasma cell surface. Clot section, H&E, x200 objective.
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Investigations showed hemoglobin (Hb) 82 g/L [normal 115-160], macrocytosis (Mean corpuscular volume (MCV) 134, [normal 80-95fl), rouleaux, White blood cell (WBC) 4.2 x 109/L [normal 4.0-11.0] with normal differential, and platelets 226 x 109/L [normal 150-400] ( Figure 1A ). Bone marrow (BM) examination showed infiltration by plasma cells (PCs) comprising up to 90% of nucleated cells including occasional binuclear and atypical PCs ( Figure 1B ). The PCs were kappa-restricted and had strong cytoplasmic CD138+ expression ( Figure 1C ).
Graphical changes over time in patient's, hemoglobin, platelet counts, and affected free light chain (FLC) over the course of disease and antimyeloma therapy. Hb, hemoglobin (g/L); Plt, platelet count (x109/L), FLC, serum free light chain (mg/L); MPV, melphalan-prednisone-velcade (bortezomib); Ld, lenalidomide and dexamethasone; DVd, daratumumab-velcade (bortezomib)-dexamethasone; PCd, pomalidomide-cyclophosphamide-dexamethasone; Id, ixazomib-dexamethasone.
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FLC and platelet count dynamics over the course of disease and treatment is shown in  Figure 2 .