Multiple Myeloma
Patient Presentation:
S.K., a 30 year old female, presented to ED with chief complaint of
persistent back and left sided rib pain, unrelieved with OTC medications and
rest. Pt states duration of pain at 3 months, but becoming increasingly
worse within last week; now rating pain 8 of 10. On physical examination,
pt was tender to palpation in left upper chest, and had tenderness on the
left scapular region. Pt was febrile to 38.3 and hypertensive at 168/86;
all other VS (HR 82, RR 16, O2 98% RA) were WNL. Labs drawn were remarkable
for anemia with Hgb 8.3 and Hct 24.3. Pt underwent a bone scan which showed
a plasmocytoma in the eighth left rib and a small lytic region on the medial
right ilium. Pt. was admitted for further evaluation.
Differential List:
Osteoblastoma, B cell non-Hodgkin’s lymphoma, Waldenstrom macroglobulinemia,
multiple myeloma
Diagnosis:
A CT scan with IV contrast of thorax, abdomen, and pelvis was performed and
again indicated a left eighth rib lesion and vertebral body lesions at T4
and T6. Pt’s free Kappa Light chain urine level was 131 mg/L (elevated and
indicative of plasma cell neoplasms), a 24 hour urine collection showed a
protein level of 360 mg (elevated), serum IgG was 4410 mg/dl (normal range
620-1400 mg/dl), and protein electrophoresis of blood showed gamma globulin
level of 2.8g/dl and total protein of 9.6g/dl (both elevated). A bone marrow
biopsy showed 20% atypical plasma cells and a tissue biopsy of the eighth
rib showed plasma cell neoplasms. Pt was diagnosed with plasma cell multiple
myeloma.
Treatment:
Pt underwent 5 cycles of palliative radiation to the left rib and began
dexamethasone 40mg PO twice a week; for pain control pt began Dilaudid® 8mg
PO q3hr prn. Prior to discharge, a mediport was placed for the pt to begin
outpatient chemotherapy to consist of Oncovin® (vincristine) and Adriamycin®
(doxorubicin).
Outcome:
The pt is currently still receiving outpatient chemotherapy, if pt does not
respond, the next option would be Thalomid® (thalidomide) followed by an
autologous stem cell transplant. A stem cell transplant is the only curative
option for multiple myeloma, the pt will need to continually follow up and
re-evaluate her disease progression with the hematology service.
Case created by Stefanie Kelly,
2011.