Dr Vivian Barrera / Dr Farhan June 20, 2013

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

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

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

Oriented TPPNon toxic lookingNeck : suppleH : S1 S2C : bibasal crepsA : soft , no palpable bladderC: supple bilaterallyDRE: Brown stools, No bloodMotor 5/5 uLE

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

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

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

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

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

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

Patient Multiple Myeloma Tuberculosis kidney/chest

MGUS

Age 91 older adultMA >60

* mean age >70

Anemia * * Not seen

Deranged Creatinine

* * Not seen

Chronic renal parenchymal disease

* Not seen

Calcium normal * *

Low VIT DOsteopenia

*

Absent skeletal lytic lesions

* * *

Infection * *

AFB Negative

B2 microglobulin Poor prognosis

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

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.

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

1% of all cancers10% of all hematologic cancerF>M (1.4.:1) IncurableDisease of older adults ( mean age:

66y.o)Small but unknown fraction of

cases are familialEvolve from MGUS

Complex , poorly understood

Establishment of a limited clonal proliferation

Progression of MGUS to MM

Genetic predispositionOlder age ImmunosupressionHormonalEnvironmental exposures

Radiation Herbicides, insecticides, benzene,

petroleum

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%

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

1. Hypercalcemia: serum calcium>2.75 mmol/L2. Renal dysfunction: serum creatinine>173 mmol/L3. Anemia: hemoglobin 2 g/dL below lower limit of normal4. Lytic bone lesions (CT and MRI may be used to identify suspicious findings on plain films)5. Symptomatic hyperviscosity6. Amyloidosis7. Recurrent bacterial infections (more than two episodes in 1 year)

FBC, blood chemistryElectrophoresis immunofixationQuantitative ImmunoglobulinXrays, Ct scan, MRI, PET BMAB2 Microglobulin

Deferred treatment if asymptomaticBisphosphonatesBlood transfusion or erythropoeitinChemotherapyAutologous stem cell transplantAllogenic SCT

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 albuminStage III

B2M >/ 5.5 mg/dl

Stage 1 Stage 1 Stage 2 Stage 3

HB > 10g/dl < 8.5mg/dl

calcium Normal > 12 mg/dl

Skeletal survey:

NormalSingle 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

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

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