Fifth Stage
Internal Medicine
Dr. Aamer – Lecture 8
1
Multiple Myeloma
Old age female presented with:
•
Backache: warning associations are (i.e. sinister
backache):
• Pallor (anemia).
• Elevated urea and creatinine (CKD).
• Hypercalcemia (Stones, bones, groans, and
moans).
▪
(Extra note: Hypercalcemia + epigastric Pain = acute
pancreatitis / peptic ulcer)
Investigations
:
•
X-Ray of skull:
o
Large multiple lytic lesions
(Pepper-salt pot skull).
▪
Real skeleton shows eaten bones.
•
Bone marrow examination:
o
Cells with large, ectopic nucleus, with white hallow
around nucleus. This is Plasma cell .
▪
In physiology, plasma cells are developed from B
lymphocyte, the plasma cell secretes antibodies
.
•
Assess clonality by flow cytometry
o
CD 38, CD 138
▪
Because plasma cells here are clonal, their antibodies are
also monoclonal.
2
•
Serum protein electrophoresis to assess those antibodies (globulins) by serum
protein electrophoresis
:
o
Normally only albumin has a spike
o
In our case, there is spike in gamma
protein (M spike). And that’s another
evidence to confirm clonality.
So, this is a case of
Multiple myeloma
!
Is malignant plasma cell dyspraxia, attacks elderly patient
(
in Iraq it attacks even younger ages
). It is non-curable disease.
Treatment
Emergency managements;
• Priority to treat hypercalcemia by excessive hydration.
◦ You can do ECG to confirm hypercalcemia by finding short QT.
• Dexamethasone (Decadron
®
), because steroid is anti-myeloma.
Novel agents (Chemotherapy):
• Bortezomib (Velcade
®)
• Lenalidomide (Revlimid
®
), an immunologist modulator.
• Daratumumab (Darzalex
®
), anti CD-38
• Zoledronic acid (Zometa
®
), osteoclast inhibitor.
For further info, read the text book `Davidson`
Thank you,,,
Some Notes were written from students…