Author : Dr . Prajwal ( MD Internal Medicine )
A 65 year old woman presents with Aches and pains in her knees, shoulders, and lower back for 3 months, in association with worsening fatigability. She has also lost weight during this time period, although extent hasn’t been measured. Her medical, surgical and family histories are unremarkable and she’s not on any medications.
She does not smoke, Drinks only socially, and is on normal diet. Her complete blood counts is significant for Hb 9.5 g/dl , WBC 3,800/mm3 , and a platelet count of 115,000/mm3. A follow up peripheral blood picture reveals normocytic, normochromic anaemia with marked rouleaux formation. Her ESR is 89 mm/ 1hr.
On our Examinations:
* Average build
* BMI : 21. 2 kg/m2
* Afebrile
* Pale
* Not Icteric
Musculoskeletal system:
* B/L shoulder and knee joins : No abnormalities
* Lumbar spine : Normal range of movement
No Point of tenderness
* Reminder Musculoskeletal system : Clinically Normal.
Case Discussion :
* Aches and Pains Are not uncommon complaints in the elderly ; In most such cases these are due to benign causes, with few or no specific interventions required. However, in an important minority, these symptoms may herald serious Underlying disease. Thus a Careful search for Potential Red Flags is essential! The elderly lady as we can see in this case is Good example in point; the relatively recent onset of symptoms and unexplained weight loss, fatigability Which should prompt our further evaluations!
Now, Her examinations Turns out be unremarkable, except for the presence of pallor; However a follow up CBC reveals a rather Alarming Finding , Pancytopenia with peripheral blood film demonstrating a normochromic normocytic anemia with marked Rouleaux formation. We should also note that her ESR is significantly increased.
Dear Medicoz, The above constellation of clinical findings and Investigations results in Highly suspicious of Hematological malignancy! Note that in this context, The presence of widespread Skeletal pain is Worrisome for MULTIPLE MYELOMA; Other KEY POSSIBILITIES to keep in mind includes Monoclonal Gammapathies and metastatic bone malignancy.
A skeletal survey and Serum protein Electrophoresis are good next step ; Over to the case the former shows generalized Osteopenia with lytic lesions in lumbar vertebrae. However serum protein Electrophoresis reveals M protein spike, with Immunofixation showing this to be IgA in nature, Making MM highly probable.
Case was proceeded with Follow up BONE MARROW BIOPSY which revealed presence of Clonal plasma cells ; In conjunction to above findings , THIS IS SUFFICIENT TO DIAGNOSE MULTIPLE MYELOMA!
Dear Medical warriors, Renal impairment and Hypercalcemia are common in these patients , a metabolic profile is also essential. Fortunately, in this case her renal profiles are normal, but mild Hypercalcemia is indeed present, and should be treated appropriately.
As she’s 65 years of age, we can consider autologus stem cell transplantation ; Bisphosphonate therapy should also be commenced, given the presence of bone pain. Note that the relatively mild anemia seen here does not mandate the treatment with recombinant erythropoietin. Plasmapharesis maybe indicated if severe paraprotenemia give rise to Hyperviscosity syndrome /if renal impairment was present.
