Case III Flashcards
(28 cards)
Pain in what level of the vertebral column should you be most worried about?
Thoracic. Thoracic back pain is more often due to serious spinal pathology than neck or low back pain.
What are some red flags for back pain?
- Age over 50
- Worsened in supine position
- Worse at night/awakens from sleep
- Band-like distribution around body
- Pain not relieved with conventional methods
- Constitutional symptoms
- Progressive neurological disorder of lower extremities
What is multiple myeloma?
B-cell malignancy characterized by neoplastic proliferation of a single clone of plasma cells producing a monoclonal immunoglobulin
What are early findings in a PT with multiple myeloma but is otherwise asymptomatic?
- Increased Total Protein (TP > 8)
- Renal Insufficiency (Cr > 2)
- Hypercalcemia (Ca > 11)
- Anemia (Hemoglobin < 10)–normocytic/normochromic
Why do you get renal insufficiency with multiple myeloma?
- Cast nephropathy from light chains
- Hypercalcemia
- Light chain amyloidosis
- Drug-induced renal damage NSAIDs
- Radiocontrast media-induced acute renal failure
- Hyperuricemia
How do bone lesions progress in multiple myeloma?
Lesions begin in medullary cavity, erode cancellous bone then destroy the bony cortex.
Why do you get hypercalcemia with multiple myeloma?
Due to increased osteoclast activity
Why do you get anemia with multiple myeloma?
- Bone marrow replacement
- Kidney damage
- Dilution in the case of large M-protein
- B12 deficiency (14% of cases)
What typically makes up the M-protein?
IgG >50% IgA 20% Light chain component only 16% IgD 2% IgE 1-3% Nonsecretory 6.5%
What are the two things that can give rise to MM?
- De novo (80%)
* MGUS (20%)
What proteins can a urine dipstick detect?
Usual dipstick reagents detect albumin & often do not detect Bence Jones proteins.
What are Bence Jones proteins?
The light chains in immunoglobulins (called Bence Jones proteins)
Diagnostic criteria for MGUS?
Serum M-proteins <10% clonal plasma cells on bone marrow
No end organ damage
Treatment for MGUS?
F/U once per year
Diagnostic criteria for SMM?
Serum M protein level of > 3 gm/dL
> 10 % clonal plasma cells on bone marrow
No end organ damage - CRAB negative
Treatment for SMM?
Observation only with labs every 3 to 4 months
SPEP, CBC, creatinine, calcium, Free Light Chain (FLC) ratio, UPEP, and urine immunofixation
Why don’t we treat SMM?
Early treatment may increase the risk for acute leukemia
Diagnostic criteria for Waldenström Macroglobulinemia
- Serum IgM M-protein of any concentration
- Bone marrow >10% lymphoplasmacytic infiltration
Symptoms of Waldenström Macroglobulinemia
Anemia – pallor
Systemic symptoms:
weakness, fatigue, weight loss, fever, night sweats
Hyperviscosity
- blurring or loss of vision, headache, epistaxis, ataxia, dementia, stroke, or coma
- dilated, segmented, tortuous retinal veins “sausage link” appearance
- treat with acute plamapheresis
Lymphadenopathy/Hepatosplenomegaly
Does not lead to bone lesions or hypercalcemia
Percentage of people that progress to MM after having solitary plasmacytoma
50%
Diagnositic criteria of solitary plastacytoma?
Low or no serum and urine M protein Bone marrow not consistent with MM
No CRAB other than single bone lesion due to clonal plasma cells
What is POEMS syndrome?
Osteosclerotic myeloma
What does POEMS syndrome stand for?
Polyneuoropathy Organomegaly Endocrinology (excluding DM or hypothyroidism) Monoclonal protein Skin changes
What are the three main indications of treatment for MM?
- End organ damage
- No end organ damage but > 60% plasma cells
- Extramedullary plasmacytoma
