|Home | About | Journals | Submit | Contact Us | Français|
A 54-year-old woman with a medical history of hypothyroidism presented to her local physician with a 2-week history of fatigue and midback pain. The patient described the back pain as aching, worse in the morning, and aggravated by movement; she rated its severity as 6 out of 10 and noted that it was not relieved by ibuprofen. Her primary physician obtained laboratory studies that were remarkable for a serum calcium level of 16.7 mg/dL. Chest radiography revealed mild curvature of the thoracic spine but was otherwise unremarkable. Notably, findings on recent mammography and colonoscopy were both normal.
The patient was admitted to our hospital for pain control and further evaluation of back pain. She had no history of fever, chills, or night sweats but had intentionally lost 27.2 kg in 14 months. She also reported increased thirst during the past month. She had a strong family history of cancer, including multiple myeloma (mother), small cell lung cancer (sister), ovarian cancer (aunt), and testicular cancer (nephew). Her son had a history of common variable immunodeficiency. The patient was taking levothy-roxine, a multivitamin, fish oil, calcium, and glucosamine/chondroitin. On examination, her vital signs were as follows: blood pressure, 138/74 mm Hg; pulse, 85 beats/min; respiration, 12 breaths/min; and temperature, 37.6°. In general, she appeared in mild distress, having difficulty finding a comfortable position while lying in bed. Otherwise, the patient's physical examination was unremarkable and her neurologic examination revealed no localizing findings. Results of the initial blood tests performed at our institution were remarkable for the following: hemoglobin, 10.4 g/dL (reference ranges provided parenthetically) (12.0-15.5 g/dL), mean corpuscular volume, 90.4 fL (81.6-98.3 fL), leukocyte count, 9.2 × 109/L (3.5-10.5 × 109/L); platelet count, 233 × 109/L (150-450 × 109/L); calcium level, 15.9 mg/dL (8.9-10.1 mg/dL); creatinine level, 2.3 mg/dL (0.7-1.2 mg/dL); blood urea nitrogen level, 34 mg/dL (6-21 mg/dL); and erythrocyte sedimentation rate, 70 mm/1 h (0-29 mm/1 h).
Multiple myeloma is a monoclonal neoplasm resulting from abnormal maturation of plasma cells with a B-lymphocyte lineage. It often progresses from a premalignant proliferation of clonal plasma cells referred to as monoclonal gammopathy of undetermined significance. The exact cause is unknown; however, myeloma is associated with exposure to radiation and petroleum products and is also seen more frequently among farmers and those working with wood and leather. Additionally, translocations, errors of switch recombination, and overexpression of MYC and RAS genes have been implicated in the pathogenesis of plasma cell disorders, including multiple myeloma. The symptoms and organ dysfunction associated with multiple myeloma reflect physiologic responses to the plasmacytoma and its products. Therefore, clinical features of myeloma include bone pain, fractures, hypercalcemia, infections, renal failure, anemia, and neurologic symptoms.19
Multiple myeloma is typically diagnosed by a marrow plasmacytosis greater than 10%, lytic bone lesions, and the presence of M proteins in the serum and/or urine. The M-component level, quantifiable by serum electrophoresis, represents the clonal secretion of immunoglobulin and is an indicator of tumor burden. Immunoelectrophoresis confirms that the M component is monoclonal. However, presence of the M component is a nonspecific finding that is seen in various other conditions, including breast and colon cancer, autoimmune diseases, sarcoidosis, cirrhosis, and even parasitic diseases.19
Current treatment strategies involve determining whether the patient is a candidate for HCT.20 If HCT is not an option, the standard of care is 12 cycles of melphalan, prednisone, and thalidomide. If the patient meets criteria for HCT, then the combination of lenalidomide and dexamethasone (as for the current patient) or a bortezomib-based regimen may be used.20 Additionally, advances in supportive care, including bisphosphonates and antibiotics, have greatly increased the quality of life of patients with multiple myeloma. Yet it must be stressed that current therapy is not curative and that patients with myeloma survive only a median of 5 to 6 years.20 The most common causes of death are progressive myeloma, renal failure, and sepsis.19
See end of article for correct answers to questions.
Correct answers: 1. a, 2. d, 3. c, 4. e, 5. b