Fig. 1

The main findings are lytic lesions of the posterior arch of the left fourth rib and the proximal left clavicle, with a pathologic fracture (arrows). There are ill-defined opacities in the right lung (red arrows). The lateral view shows a definite extrapulmonary mass (red arrow) and a small pleural effusion. CT shows diffuse skeletal involvement with accompanying soft tissue masses (arrows). The differential diagnosis of this pattern in an adult rests basically between metastatic disease and myeloma.

Fig. 2

Final diagnosis: multiple myeloma. Follow-up chest film after treatment shows regression of the soft tissue masses (Fig. 3).

Fig. 3

Congratulations to Genchi Bari, who suggested the correct diagnosis.

Teaching point: remember that haematologic processes (mainly myeloma) should be included in the differential diagnosis of widespread lytic lesions.