5. HISTORY
ď40 years old married gentleman , resident of Sialkot
admitted through A/E on 12 th may 2015 with
presenting complain of :
ďAltered state of consciousness âŚ3 days
6. HOPI
ďAltered state of consciousness âŚ3 days
ďInsidious
ďGradually worsened
ďAssociated with headache , blurred vision and epistaxis
ďNo H/O of any limb weakness or deviation of angle of mouth .
ďNo H/O ocular paresis
ďNo H/O fits , vomiting
7. Preceding history
ďGeneralized aches and painsâŚ3 months
ďGradually worsened
ďpartially relieved by taking NSAIDS
ďAggravated by daily activities
ďAssociated with low grade fever
8. Preceding history
ď Low backache For âŚ.2 months
ďInsidious in onset
ďRadiating to buttocks
ďAggravated by sitting and walking
ďRelieved partially by taking injectable NSAIDS and opioids
ďNo H/o numbness of feet
ďNo H/o urinary retention and constipation
9. Preceding History
⢠H/O off and on decreased urine output âŚ2 months
⢠Dysuria and Frothing in urine
⢠Swelling in feet
⢠Relieved on oral and injectable diuretic therapy
⢠No history of passage of stone in urine
⢠No history of lumbar and hypogastric pain
10. Systemic review
ďH/ O Weight loss (not documented )
ďAnorexia
ďOff and on H/O minor gum bleed and epistaxis
ďOff and on H/O low grade fever
ď Dyspnea on exertion with productive cough
11. Systemic review cont
ďNo H/o angina ,orthopnea and PND
ďNo H/o hematemesis , melena , and alteration in bowel habits
ďNo H/O joint pains ,swelling ,photosensitivity ,skin ulcers and
alopecia
ďNo H/o hematuria , pyuria and lumbar pain
12. Past Medical and surgical history
ďHistory of multiple outpatient visits in vicinity
ďBeen treated as a case of spinal TB
ď2 months back ATT taken for 4 weeks
ďNo history of any surgical procedure
13. Drug history
ďRepeated parenteral NSAIDS and opioids
ďDiuretic therapy , furosemide
ďAllopurinol for hyperuricemia
ďPPIâs
ďNo H/O any known drug allergy
14. ďAlive and healthy children
ďNo history of any chronic or malignant disease in family
ď Belong to Middle class
ďOccasional smoker
ďNo H/O alcohol and drug abuse
ďNo H/o intimate extramarital sexual contact
Family history
Socioeconomic and personal history
15.
16. GPE
⢠Middle aged gentleman ,semi conscious and disoriented
lying on bed having GCS ..E3 V3 M6
⢠Vitals
BP: 110/70 mmHg
Pulse: 88 bpm
R/rate : 18 breaths per minute
Temp: Afebrile
SO2: > 90% @ room air
⢠Severely dehydrated and pale .
17. CNS
ďPupils : Bilaterally equally reactive to light and
accommodation
ďSigns of meningeal irritation : Negative
ďMoving all limbs
ďPlanters B/L down
18. ďCHEST : Normal vesicular breathing all over
ďPRECORDIUM: S1 and S2 no added murmur appreciated
ďABDOMEN : soft , non tender
⢠Liver palpable (17 cm liver span)
Regular margins and smooth surface
ďMusculoskeletal : generalized bone tenderness but no
obvious joint swelling and deformity.
29. Initial Treatment
ďInitial rehydration with 0.9% N/Saline @100 ml /Hour .
ďPassage of Nasogastric tube and foley catheter
ďCommencement of Broad spectrum i.v antibiotics
ďI.V PPIs
ď Strict I/O monitoring
ďVitals monitoring
ďIntensification of therapeutic as well as diagnostic modalities
on the basis of the initial lab work obtained
37. Final Diagnosis
ďHyper viscosity syndrome secondary to paraproteinemia
related to multiple myeloma
ď§ Bone Marrow Plasma cell Infiltration
ď§ Hypercalcemia
ď§ Renal failure
ď§ Severe dehydration
ď§ Vertebral compression fractures
ď§ Diuretic induced Hypokalemia
ď§ Hyperuricemia
38. Specific and Intensified Treatment
ďConsultation with hematology department for plasmapharesis
concerning Hyperviscosity related to paraproteinemia
ď Laision with hematology regarding specific chaemotherapy
ďThree sessions of plasmapharesis with FFPâs as a
replacement fluid
ďWhile monitoring and keeping eye on other parameters
39. While at the same time
ďSaline diuresis continued and I.V bisphosphonates given for
hypercalcemia
ďXanthine Oxidase Inhibitors for Hyperuricemia
ďParenteral potassium replacement
ďPatient responded well to therapeutic measurers
40.
41. WHAT is viscosity
ď Viscosity is a quantity expressing the magnitude of internal
friction in fluid as measured by force per unit area resisting uniform
flow
ďNormal blood viscosity is < 1.8 centipoise
ďHyper viscosity is abnormally thick and viscous blood
ďPlasma hyperviscosity(HVS) is defined as a value above the
mean +2SD limit determined for normal plasma
42. Hyper viscosity Syndrome(HVS)
ďGroup of symptoms triggered by increase in viscosity of blood
causing impaired microcirculation ,
vascular stasis and hypoperfusion.
ďHematological emergency and
can be life threatening
46. Introduction
ďMalignant B- cell (plasma cells) proliferation derived from a
single clone .
ď1% of all malignancies(2% in blacks)
ď13 % of hematological malignancies(33% in blacks)
ď2500 new cases per year in UK
ďMedian age at diagnosis is 65-70 years
47. INTRODUCTION CONT:
⢠Males >> females ..Blacks>> whites
⢠Ethnic differences , lowest incidence in Asians compared to
afro Caribbean and Caucasian population
⢠Radiation , benzene ,pesticide exposure and farm working etc
⢠Chromosomal abnormalities ..bad prognosis
48. Multiple myeloma
features
⢠HyperCalcemia
⢠Renal failure
⢠Anemia
⢠Bone pains
⢠Constitutional symptom
⢠Hyperviscosity
⢠Recurrent bacterial infections
Fever ,abdominal pain, Nausea ,
diaphoresis,Weight loss
Tumour burden, Osteoclastic activity
Osteoporosis, compression fractures
Hypercalcemia,Cast nephropathy
Recurrent Infections ,Renal stones
NSAID induced ,Chemotherpay
Paraproteinemia ,Hypoperfusion
Retinal artey and vein obstruction
Mucosal bleeds menorrhagia
Hypogammaglobulinemia
Chemotherapy related
Marrow infiltration
Cytopenias
Altered mental status,
Confusion, depression
Weakness ,Dehydration
Kidney stones
C
R
A
B
49. Myeloma related organ damage
⢠Elevated calcium levels
⢠Renal insufficiency
⢠Bone marrow infilteration
⢠Bone lesions
⢠Hyperviscosity
⢠Amyloidosis
⢠Recurrent bacterial infections
53. General Aspects
i. Analgesia
ii. Monitor renal function
iii. Local radiotherapy
iv. Spinal support
i. High fluid input
ii. Rapid treatment of hypercalcemia
iii. Caution with nephrotoxic drugs
iv. Chemotherapy
i. Bisphosphonates
ii. Hydration
iii. Loop diuretics
i. Xanthine oxidase inhibitors
i. Local radiothearpy
ii. Fixation of fracture
iii. Bisphosphonate prohylaxis
ďśPain control
ďśRenal impairment
ďśHypercalcemia
ďśHyperuricemia
ďśBone disease
Recurrent Bacterial infections
Require Anitbiotics
paraproteinemia
Plasmapharesis ,
Primary disorder
54. Specific Management
⢠Variable regime chemotherapeutic options
⢠Stage and extent dependant
⢠Possibility and availability of curative stem cell
transplant