The n e w e ng l a n d j o u r na l of m e dic i n e

Images in Clinical Medicine

Chana A. Sacks, M.D., Editor

Raindrop Skull

A 
Fabio Solis, M.D. 46-year-old man presented to the emergency department with
Cesar Gonzalez, M.D. a 1-month history of fatigue, shortness of breath, and low back pain and
Hospital General de Mexico report of a weight loss of 30 kg over the previous 10 months. On physical
Mexico City, Mexico examination, his conjunctiva and palms were pale. Laboratory evaluation revealed
fabiosolisjimenez@​­gmail​.­com a hemoglobin level of 4.9 g per deciliter (reference range, 12 to 16), a creatinine
level of 5.4 mg per deciliter (480 μmol per liter; reference range, 0.4 to 1.0 mg per
deciliter [35 to 88 μmol per liter]), and a calcium level of 12 mg per deciliter (3 mmol
per liter; reference range, 8.9 to 10.3 mg per deciliter [2.2 to 2.6 mmol per liter]).
A skeletal survey showed diffuse osteopenia, a pubic bone fracture, and numerous
radiolucent lesions on the skull, which had an appearance known as “raindrop
skull” — a pattern of lytic or punched-out lesions that resemble raindrops hitting
a surface and splashing. These findings are characteristic of multiple myeloma.
The diagnosis was confirmed by bone marrow biopsy and aspirate samples that
showed 50% clonal plasma cells in the marrow; serum protein electrophoresis
revealed a monoclonal IgA paraprotein. Initial management included red-cell trans-
fusion for treatment of anemia and hydration to correct hypercalcemia. The patient
did not respond well to induction therapy and died 3 months after diagnosis.
DOI: 10.1056/NEJMicm1714471
Copyright © 2018 Massachusetts Medical Society.

1930 n engl j med 378;20 nejm.org  May 17, 2018

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