1. DrVivian Barrera / Dr Farhan
June 20, 2013

2.  91 y.o. Chinese female
 Premorbidly
 ADL assisted
 Ambulant with WF
 Independent in grooming and feeding
 BARTHEL 12/20
 AMT 6/10
 Social
 Widowed
 1 adopted daughter :Main carer

3.  DM
 HBAIC : 6.1 13/5/13
 HYPERTENSION
 HYPERLIPIDEMIA
 TB OF KIDNEYS 1980
 Bleeding GIT 2009
 -extensive diverticular
disease
 - Antral erosions
 Fracture Right IT 4 S/P
DHS 2006
 Fracture left IT s/P PFNA
in 2010
 Fall 5/2013 with Left
Olecranon fracture
 S/P ORIF left Olecranon
 Left Humerus Fracture
▪ Conservative management
▪ Discharged to AMKCH for rehab
▪ BMD: T score -2.2 2010

4.  6/5 /2013
 Spiked fever (+) cough
 Bibasal creps (+) SOB , SP02 89%-95%
 CXR: no consolidation/ effusion
 CPR 1 TW 6.8 PLT: 203 crea 98
 UFEME: suggestive of UTI
 Urine CS: Proteus
 Given IV Rocephine, Flagyl
 10/5/2013 Repeat bloods
HB 8.8 TW 5.9 crea 187, Na 140 K 3.7

5.  Oriented TPP
 Non toxic looking
 Neck : supple
 H : S1 S2
 C : bibasal creps
 A : soft , no palpable bladder
 C: supple bilaterally
 DRE: Brown stools, No blood
 Motor 5/5 uLE

8.  Hb 9.3
 MCV 98.2 H
 MCH 32.4 H
 MCHC 33
 TW 5.9
 Plt 258
 Crea 179 H
 Urea: 6.7
 TCalcium 2.09L
 Cor Ca 2.35
 iPhosphate 1.36
 Vit B12 209
 Folate : 5.20
 Transferrin 1.29
 Ferritin 270.7
 Iron serum 12.1
 Iron sat 42%
 Haptoglobin 157
 Vit d 5ug/L
 CRP 8.0
 Procalcitonin 0.27
 PTH 19.68

9.  TSH 12.9
 T4 0.719
 Hbaic 6.1
 Albumin 25
 CK Normal
 LFT: Normal
 APTT /PT Normal

 UFEME 23/48/0
 (-) protein
 (+) esterase
 Urine CS: NBG
 Sputum CS: normal
flora
 AFB Smear: negative
x3 takings

10.  Fracture Distal shaft of fifth Metatarsal bone L
 Xray toes:
 diffuse bony osteopenia, healing fracture of distal
shaft of the fifth metatarsal bone noted
 Seen By ORTHO
 Casting done

13.  23/5
 Urine PCR 2.07
 UFEME 20/270/0 (+) protein (+) esterase
 ANA screen negative
 ENA screen negative
 DsDNA <25
 ANCA
 Anti MPO negative
 Anti PR3 negative

16.  Patient doesn’t qualify for DDX of MM
 Crea -->Prob post TB Kidneys and CRPD
 M band is just 3G/L
 Calcium is normal
 Anemia not completely worked up
▪ for skeletal survey
▪ B2 Macroglobulin

17.  There is no evidence of lytic lesions in skull
or the bones to suggest presence of MM
deposits
 Unlikely MM, (?) likely MGUS
 Needs Further anemia WU
 Not for BMA
 BETA 2 MACROGLOBULIN 14,392

19. Patient Multiple Myeloma Tuberculosis
kidney/chest
MGUS
Age 91 older adult
MA >60
* mean age >70
Anemia * * Not seen
Deranged Creatinine * * Not seen
Chronic renal
parenchymal disease
* Not seen
Calcium normal * *
Low VIT D
Osteopenia
*
Absent skeletal lytic
lesions
* * *
Infection * *
AFB Negative
B2 microglobulin Poor prognosis

20.  Diagnosed only if
 Serum Monoclonal Protein( IgA, IGg, IgM) < 3
g/dl)
 Clonal BM plasma cells < 10%
 Absent of lytic lesions. Anemia, hypercalcemia,
renal insufficiency ( end organ damage) that can
be attributed to plasma cell proliferative disorder

21.  Past TB of kidney
 Discordant kidney size
 Recurrent or resistant urinary tract infection, sterile pyuria
with or without hematuria .
 Renal (hydronephrosis/pyonephrosis)
 Renal failure (Chronic kidney disease due to parenchymal
infection and obstructive uropathy
 Infertility and pelvic inflammatory disease.
 Urine AFB smear ( 55% sensitivity)
 Urine AFB culture ( 41% sensitivity)
Indian J Urol. 2008 Jul-Sep; 24(3): 401–405.

22.  Older age
 Anemia , leukopenia, low albumin
 Unexplained renal dysfunction
 Multiple fractures
 Elevated b2 macroglobulin
 M proteins
 Raised IgA, ( 20% of MM)
 Protein electrophoresis
 Raised K/L freeLight chains ( 20% of MM)
 Immunofixation : (+) monoclonal bands

23.  1% of all cancers
 10% of all hematologic cancer
 F>M (1.4.:1)
 Incurable
 Disease of older adults ( mean age: 66y.o)
 Small but unknown fraction of cases are
familial
 Evolve from MGUS

24.  Complex , poorly understood
 Establishment of a limited clonal
proliferation
 Progression of MGUS to MM

25.  Genetic predisposition
 Older age
 Immunosupression
 Hormonal
 Environmental exposures
 Radiation
 Herbicides, insecticides, benzene, petroleum

26.  Anemia 73 %
 Bone pain 58%
 Inc creatinine 48%
 Fatique 32%
 Hypercalcemia 28%
 Weight loss 24 %
 Paresthesias 5%
 Hepatomegaly 4 %
 Slenomegaly 1%
 Lympadenopathy 1 %
 Fever 0.7%

27.  Presence of M –protein in serum
 No specific level of m-protein is used as a cut off
value
 40% percent of patients with symptomatic MM
will have an M protein of < 3 g/dl
 Presence of 10% clonal bone marrow plasma
cells
 Related organ or tissue impairment
 CRAB

28. 1. Hypercalcemia: serum calcium>2.75 mmol/L
2. Renal dysfunction: serum creatinine>173 mmol/L
3. Anemia: hemoglobin 2 g/dL below lower limit of
normal
4. Lytic bone lesions (CT and MRI may be used to
identify suspicious findings on plain films)
5. Symptomatic hyperviscosity
6. Amyloidosis
7. Recurrent bacterial infections (more than two
episodes in 1 year)

29.  FBC, blood chemistry
 Electrophoresis
 immunofixation
 Quantitative Immunoglobulin
 Xrays, Ct scan, MRI, PET
 BMA
 B2 Microglobulin

30.  Deferred treatment if asymptomatic
 Bisphosphonates
 Blood transfusion or erythropoeitin
 Chemotherapy
 Autologous stem cell transplant
 Allogenic SCT

31.  Stage I
 B2 M < 3.5g/dl, albumin >/ 3.5g/dl
 Stage II
 B2M < 3.5mg/dl, alb <3.5g/dl or
 B2M 3.5—5.5 mg/L irrespective of serum albumin
 Stage III
 B2M >/ 5.5 mg/dl

32. Stage 1 Stage 1 Stage 2 Stage 3
HB > 10g/dl < 8.5mg/dl
calcium Normal > 12 mg/dl
Skeletal survey: Normal
Single plasmacytoma or
osteoporosis
3 or more lseions
Serum paraprotein
level
< 5 g/dl If IgG
<3 g/dl id IgA
 7 g/dl
 5 g/dl 9.31
Urinary light
chains excretion
< 4 g/24h > 12 g/24
Survival rate 62 mos 45 mos 29 mos

34.  Myeloma screen :
 M Band 3/G/L
 IgG 5.88 N
 IgA: 9.31 Increased
 IgM 0.21 N
 K/L ratio: O.o6 decreased
 Kappa free light chain: 37.9 increased
 Lambda free light chain : 607 increased

35.  Urine electrophoresis
 Protein electrophoresis
 Monoclonal band detected and bands in alpha 1,
alpha 2, beta and gamma globulin regions seen
 Immunofixation electrophoresis
 Monoclonal band detected with anti lambda
 Total protein urine
 1.94g/L