A 54-year-old man with a past history of hypertension presented for flank and lower back pain. He went to a clinic when the pain started a month earlier, and was put on muscle relaxants that helped for a short time. He also had some nausea, vomiting, and weight loss. He presented to the ED for worsening pain.
His initial plain radiography and CT scan are shown. The x-ray of his lumbar spine shows approximately 6 mm of anterolisthesis of L5 on S1. Wedging of the inferior posterior aspect of the L5 vertebral body with sclerosis of the inferior endplate of L5 and the superior endplate of S1 are seen. The L5-S1 disc space is markedly narrowed, and there is mild wedging of the L1 vertebral body). The CT shows extensive lytic osseous lesions involving the axial skeleton.
What is his diagnosis? What other lab tests might be abnormal in the emergency department?
Find the diagnosis and case discussion on p. 20.
Diagnosis: Multiple Myeloma
This patient has a new diagnosis of multiple myeloma. One needs to think about this diagnosis if a patient presents with lytic bone lesions on routine films, symptoms of malignancy, hypercalcemia, or acute renal failure. He ended up having all of these features. His initial plain film did not explicitly show lytic spine lesions, but he did have acute renal failure with a creatinine of 3.46 mg/dl (normal 0.70-1.30 mg/dL) and hypercalcium with a level of 15.1 mg/dL (normal 8.6-10.3 mg/dL). He was also anemic with a hemoglobin of 9.2 g/dL (normal 14.3-18.1 g/dL), and had some unexplained weight loss. With these concerning results and history, we ordered the CT scan, which showed multiple lytic osseous lesions throughout his back.
Multiple myeloma is a cancer of the plasma cells. The abnormal plasma cells accumulate in the bone marrow and interfere with normal blood cells. Most cases also produce a paraprotein that can cause kidney problems. (Lancet 2009;374:324.) It is the second most frequent hematologic malignancy. The median age of diagnosis is 69, and it occurs in about six per 100,000 people per year. The five-year survival rate is about 45 percent. (National Cancer Institute; http://1.usa.gov/1G3TI8P.)
An easy way to remember what multiple myeloma can cause is to use the mnemonic CRAB. This patient had all of these characteristics: elevated Calcium, Renal failure, Anemia, and Bone lesions. (Br J Haematol 2003;121:749.) Ninety percent of patients will develop lytic bone lesions during the course of their disease. (Ann Oncol 2005;16:1223.) Ten to 20 percent of patients, however, can have normal plain radiographs, and will need more sensitive imaging to see the lytic lesions. (Cancer Imaging 2004;4[Spec No A]:S47.)
Plain radiographs cannot always distinguish between osteoporosis caused by malignancy and other causes, as in this case where the initial radiograph did not show lytic bone lesions. CT or MRI can be considered for patients who have negative plain films but a high level of concern for malignancy.
It is important to remember that with the breakdown of bones comes the increase of calcium in the blood stream. It is important to check the calcium level and to treat the patient as needed. This patient had a very high calcium level, and was started on intravenous fluids. Like this patient who presented in acute renal failure, multiple myeloma often causes the excretion of proteins that can harm a patient's kidney.
Multiple myeloma can also cause anemia because the malignant cells infiltrate the bone marrow and interfere with red blood cell production. This patient had classic symptoms for a new diagnosis of Multiple myeloma.
He spent 15 days in the hospital, and had a bone marrow biopsy that showed IgA kappa multiple myeloma. He is currently out of the hospital and being treated with chemotherapy.
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