You just spent the last three months on off-service rotations and you’re so relieved to be back home in your ED.
You arrive 30 minutes early to your first shift and high five all the ED nurses, technicians, patient care assistants, the clerk, your attending, and the maintenance staff with a big smile on your face as you begin to get sandwiches and water for all the patients. Your senior resident is worried and asks if you’re sick and need to go home.
Your first patient is a 54-year-old woman who tells you she has had one week of total body pain. She has had poor appetite and fatigue with nausea and has been constipated. There is no vomiting, diarrhea, fever, chest pain, shortness of breath, or urinary changes, and there is nothing abnormal on her physical exam. The patient has not seen a medical provider in 10 years.
You send basic labs and run through your differential of over 100 different possible causes for this presentation including simple constipation secondary to low fiber diet.
Labs:
Sodium 143 mEq/L
Potassium 4.5 mEq/L
BUN 23 mg/dL
Creatinine 3.1 mg/dL
Calcium 13.5 mg/dL
Magnesium 2.2 mEq/L
WBC 15 x109/L
Hemoglobin 8.2 g/dL
Platelets 130 x 109/L.
What is multiple myeloma? Multiple myeloma occurs with malignant proliferation of plasma cells. The majority of patients with multiple myeloma present with signs and symptoms caused by plasma cell infiltration into bone and other organs or caused by kidney damage from light chain excess. Calcium is released into the bloodstream when osteoclast-activating factors result in extensive local bone destruction (4). It accounts for 1 to 2 % of all cancers and about 17% of all hematologic malignancies in the US (5).
What are the presenting symptoms? The most common presentation of a patient with multiple myeloma is bony pain, generalized weakness, and weight loss. Other symptoms include polydipsia, polyuria, and altered mentation (1,2).
What are the clinical signs? Common laboratory results include anemia, hypercalcemia, elevated creatinine (2). Other clinical presentations include bone pain with lytic lesions on routine films, increase in total serum protein or presence of monoclonal protein in the urine or serum, or acute renal failure with negative urinalysis or nephrotic syndrome (3).
What further workup is needed? Tests should include complete blood count and differential with peripheral smear and chemistry screen including calcium, creatinine, albumin, LDH, beta-2 microglobulin, and CRP. In addition, patients with suspected multiple myeloma should have bone marrow aspiration and biopsy, urinalysis and a serum protein electrophoresis with immunofixation performed either as an inpatient or as soon as possible as an outpatient (4). Cross-sectional imaging such as skeletal survey, whole body low-dose CT, PET scan, or whole body MRI may also be indicated for assessment of osseous an extra-osseous manifestations of multiple myeloma (6). Normal saline infusion is the first line treatment and glucocorticoids may be helpful. Hemodialysis should be considered for patients who cannot tolerate fluid, exhibit renal failure, or exhibit altered mental status (1).
1. Fleischman RJ. Hematologic and Oncologic Emergencies. In: Tintinalli JE, Cline DM. Tintinallis emergency medicine manual. 7th ed. New York: McGraw-Hill Medical; 2012: 678-684
2. Kyle RA, Gertz MA, Witzig TE, et al. Review of 1027 Patients With Newly Diagnosed Multiple Myeloma. Mayo Clinic Proceedings 2003;78(1):21–33
3. Kariyawasan C, Hughes D, Jayatillake M, Mehta A. Multiple myeloma: causes and consequences of delay in diagnosis. Qjm 2007;100(10):635–40.
4. Rajkumar SV. Clinical features, laboratory manifestations, and diagnosis of multiple myeloma. Post TW, ed. UpToDate. Waltham, MA: UpToDate Inc.
5. Siegel RL, Miller KD, Jemal A. Cancer statistics, 2018. CA: A Cancer Journal for Clinicians 2018;68(1):7–30.
6. Derlin T. Imaging of multiple myeloma: Current concepts. World Journal of Orthopedics 2014;5(3):272.
*Disclaimer: This post is for Board Review and is not necessarily based on up-to-date evidence.
aaurreco
Latest posts by aaurreco (see all)
- The Case for Advocacy and Social EM Training - July 2, 2020
- Protected: /Dualityofman.zoom.us - April 16, 2020
- Treating Neonatal Fever in the ED - January 29, 2019
0 Comments