This document presents the case of a 69-year-old Thai woman who presented with right hip pain for one month. Her physical examination revealed tenderness on hip rotation tests on the right side. Laboratory tests showed anemia, elevated creatinine, and presence of Bence Jones proteins in her urine, consistent with multiple myeloma. The document then provides background information on multiple myeloma, including its clinical presentation, diagnostic workup, criteria for diagnosis, and treatments for multiple myeloma and its complications.

1. EXTERN CONFERENCE
Sapakorn Wiriyangkura
5 Aug 2016

2. CASE
PP : หญิงไทย 69 ปี
CC : ปวดสะโพกขวามา 1 เดือน
PI : ประมาณ 1 เดือนก่อนเริ่มมีอาการปวดขัดๆบริเวณสะโพกและต้นขาขวา ปวด
ตลอดเวลา ไม่มีร้าวลงขา ก่อนหน้านี้ไม่มีปวดบริเวณนี้มาก่อน ปวดมากขึ้นเวลาเดิน-ลง
น้้าหนัก พอเดินได้ ไม่มีชา ไม่มีอ่อนแรง อาการปวดเป็นมากขึ้น มีปวดกลางคืนบางครั้ง
ไม่มีไข้ ไม่มีเบื่ออาหาร ไม่มีน้้าหนักลด รู้สึกเหนื่อยเพลียมากขึ้น ยังพอท้างานบ้านได้

3.  PH : underlying Hypothyroid
 Current med : Levothyroxine (0.1) 1 tab po pc
 Deny Hx of Drug allergies
 Deny Hx of smoking and alcohol used
 Family Hx : unremarkable

4. PHYSICAL EXAMINATION
 General appearance :Thai eldery female, good conscious
 HEENT : marked pale conjunctiva, anicteric sclera
 LN : Can’t palpable
 Heart : No active precordium, No heaving, No thrill
Pansystolic murmur gr.III at RUPSB, LPSB
 Lung : equal breath sounds, Fine crepitation Both lungs
 Abd : not distend, soft not tender
 Neurologic exam : Grossly intact

5. MUSCULOSKELETAL EXAM.
 Rt. Hip
 not seen gross lesions, no swelling
 Full active ROM
 No point of tenderness
 Anvil’s test : negative
 Rolling test : positive
 FABER test : positive
 Lt.Hip
 No swelling
 Full active ROM
 No point of tenderness
 Anvil’s & Rolling test : negative
 FABER test : negative

6.  Rt.Knee
 No GenuValgus/Varus
 Ballotement : Negative
 Not tender along joint line
 Crepitus on movement
 Full active ROM
 Lt.Knee
 No GenuValgus/Varus
 Ballotement : Negative
 Not tender along joint line
 Crepitus on movement
 Full active ROM

7. DIFFERENTIAL DIAGNOSIS

8. Film Both hip AP

9. RT. FEMUR AP, LAT
Rt. Femur AP,Lat

11. INVESTIGATIONS
CBC
WBC 4400 PMN 56%, LY 27% MO 11%
Hct 18 % MCV 88 fl
Platelet 151000

12. BLOOD CHEMISTRY
 Chol 61
 DB / TB 0.1 / 0.4
 AST / ALT 13 / 19
 ALT 64
 Sodium 133.4
 Potassium 3.32
 Chloride 99
 Bicarb 28
 BUN 17.5
 Creatinine 1.17
 Calcium 10.5
 Phosphorus 3.2
 Albumin 1.5
 Globulin 13.2

13. URINALYSIS
 Urine Protein 4+
 RBC 1-2
 WBC 5-10
 Hyaline cast 3-5
 Squamous epithelium 0-1
 Bladder epithelium 0-1
 Bence Jones protein : Positive

14. MULTIPLE MYELOMA
Knowledge section

15. MULTIPLE MYELOMA
Neoplastic proliferation of immunoglobulin-producing plasma cells
Infiltrated plasma cell and excess light chains immunoglobulin cause
organ failure

16. CLINICAL PRESENTATION
 Anemia – 73 percent
 Bone pain – 58 percent
 Elevated creatinine – 48 percent
 Fatigue/generalized weakness – 32 percent
 Hypercalcemia – 28 percent
 Weight loss – 24 percent, one-half of whom had lost ≥9 kg
Kyle RA, Gertz MA, WitzigTE, et al. Review of 1027 patients with newly diagnosed multiple myeloma. Mayo Clin Proc
2003; 78:21.

17. WORK UP
 CBC including Peripheral Blood smear
 Serum chemistry , Calcium, Albumin, creatinine
 Serum Free light chain
 serum protein electrophoresis (SPEP) with immunofixation and quantitation of
immunoglobulins
 Urinalysis
 Bone Marrow aspiration and study
 Metastatic bone survey-lateral skull frontal / chest film / CTL spine
Shoulders / pelvis / femurs

18. Definition of multiple myeloma
Clonal bone marrow plasma cells ≥10% of biopsy-proven bony or extramedullary plasmacytoma* and any one or more of the
following myeloma-defining events:
•Evidence of end-organ damage that can be attributed to the underlying plasma cell proliferative disorder, specifically:
• Hypercalcemia: serum calcium >11 mg/dL
• Renal insufficiency: creatinine clearance <40 mL per min (>2 mg/dL)
• Anemia: normochromic normocytic anemia (Hemoglobin < 12 g/dL)
• Bone lesions: one or more osteolytic lesions on skeletal radiography, CT, or PET-CTΔ
•Any one or more of the following biomarkers of malignancy:
• Clonal bone marrow plasma cell percentage* ≥60%
• Involved:uninvolved serum free light chain ratio◊
≥100
• >1 focal lesions on MRI studies
§
Revised International Myeloma Working Group diagnostic criteria for multiple myeloma and smoldering multiple
myeloma
Modified from Rajkumar SV, Dimopoulos MA, Palumbo A, et al. International Myeloma Working Group updated criteria for the
diagnosis of multiple myeloma. Lancet Oncol 2014; 15:e538.

19. SMM AND MGUS
Rajkumar SV, Dimopoulos MA, Palumbo A, et al. International Myeloma Working Group updated criteria for the diagnosis of multiple
myeloma. Lancet Oncol 2014; 15:e538.

20. TREATMENTS OF MULTIPLE MYELOMA
 Chemotherapy
 Corticosteroids
 Stem cell transplantation
Work up for occult
infection
SputumAFB
Stool for parasite

21. TREATMENT OF COMPLICATIONS OF MM
Spinal Cord Compression
- Spinal immobilization
- Dexamethasome 10 mg IV stat
then 4 mg iv q 6 hr halves dose every 3 days
- PPI for prophylaxis of GI bleeding

22. HYPERCALCEMIA
If dehydration, vomiting, confusions -> Admit
 IV hydration with 3-6 L of 0.9% NaCl with 40-80 mEq of potassium chloride per liter over
24 hours
 Furosemide, 40-160 mg IV over 24 hours
 Bisphosphonates: Pamidronate, 60-90 mg IV over 2-4 hours
 Corticosteroids: 200-300 mg of hydrocortisone per day or equivalent
 Consider dialysis if impaired renal function

23. BONE PAIN AND FRACTURES
Physical activities, avoidance of injury
Radiotherapy
Analgesics (avoid NSAIDs)
Bisphosphonate : prevent further bone lysis and fractures

24. THANK YOU