mp3: http://www.zshare.net/audio/50657735867014b1/

A 26-year-old man experienced the sudden onset of back pain. 17 days before admission, he bent down to lift something and felt a sudden snap in his back, followed by pain that was associated with profuse diaphoresis and muscle spasms that extended from the left shoulder to the buttocks but did not radiate to the legs. Approximately 8 months before admission, dyspnea on exertion developed; it was attributed to exertional asthma and was treated with metered-dose inhalers. He had had chronic, intermittent lower back pain after a fracture of the L1 vertebra in a sports-related injury 9 years earlier

MRI disclosed a pathologic fracture of the T9 vertebral body. A chest X-ray and CT of the chest showed a mass in the upper lobe of the left lung, with involvement of the hilar and mediastinal structures. The differential diagnosis of a pulmonary nodule is broad, however, signal abnormalities of the bone marrow noted on MRI of the spine, the constellation of pulmonary findings on CT, and the very high levels of protein and lactate dehydrogenase in the pleural fluid, even in the absence of malignant cells — were most consistent with a neoplastic process.