Multiple myeloma

Here's a case that I have seen -

A 55 year old male, shepherd by occupation, presented to the OPD with the chief complaints of fever (on and off), loss of appetite, headache, body pains, generalized weakness since 2 months, cough since 2 weeks and vomitings and pain abdomen since 2 days.

The patient was apparently assymptommatic 2 months back

Then he developed fever which was insidious in onset, low grade fever, intermittent type.

It is associated with chills and rigors

There are no aggravating factors and the fever was relieved on taking medication

(For which he visited the RMP)

It is associated with generalized weakness, headache (diffuse), neck pain, loss of appetite and weight loss.

It is associated with cough since 2 weeks

It is productive in nature. The sputum is mild in quantity, white in colour, non-purulent, non-blood stained, non-foul smelling.

H/O shortness of breath on exertion

H/O vomitings since 2 days

1 episode/day containing ingested food particles.

Non-bilious, non-blood stained, non-projectile

H/O pain abdomen since 2 days in the right hypochondrium, non- radiating

No H/O loose stools

No H/O chest pain, palpitations, orthopnea, paroxysmal nocturnal dyspnoea

(He visited a hospital in Nalgonda as his complaints didn't subside after taking the medication given by the RMP and then he was referred to Kamineni, Narketpally.)

Past History -

H/O similar complaints 1.5 years back for which he visited a hospital in Nalgonda.

Patient developed fever and generalised weakness 1.5 years ago after which he was diagosed with Anemia and 2 units on PRBCs were transfused.

Not a K/C/O DM, HTN, TB, Epilepsy, Asthma, CVA, CAD

H/O surgery for hydrocele 5 years back

Personal History -

Mixed diet

Decreased appetite

Adequate sleep

Regular bowel and bladder movements

Regular intake of alcohol and beedi (4-5/day) since 35 years.

Patient started consuming alcohol 35 years ago and used to consume about 90ml of whiskey everyday. He started consuming alcohol due to peer pressure and also because he felt relieved after consuming alcohol after work.

The patient stopped smoking beedi 4 years back and he stopped consuming alcohol 4 months back and also stopped going to work due to his health issues (Fatigue)

O/E

Patient is C/C

Poorly built, poorly nourished

Pallor is present

No icterus, cyanosis, clubbing, lymphadenopathy, edema

Vitals -

Temperature - Afebrile

BP - 100/60 mmHg

PR - 120 BPM, Regular

RR - 25 CPM

SPO2 - 94% on RA

CVS - S1, S2 heard, No murmurs

RS - BLAE present, NVBS

P/A - Soft, Non-tender. No organomegaly

CNS - NAD

Investigations-

Day 1-

Hemogram

Bleeding and Clotting Time

ESR

Reticulocyte Count

Peripheral Smear

LFT

RFT

ABG

Chest X-Ray

X-Ray Skull

ECG

USG Abdomen -

1. Right mild pleural effusion

2. Right small kidney with normal echogenicity

HRCT Chest -

1. Moderate to gross right pleural effusion

2. Multilobar consolidations of the right lung, involving upper and middle lobes

3. Passive collapse of basal segments of right lower lobe

Day 2-

Hemogram

RFT

ABG

Spot Urine Protein/Creatinine Ratio

Sputum for CBNAAT - Positive

(Blood transfusion was done on Day 2)

Day 3 -

Hemogram

ABG

RFT

Chest X-Ray

(Pleural Tap was done)

Serum Protein Electrophoresis

(Blood transfusion was done again on Day 3)

24 Hours Urinary Proteins

24 Hours Urinary Creatinine

Thyroid Profile

Blood Culture and Urine Culture showed no growth

Sputum (For AFB, Gram's stain and Culture and Sensitivity)

Day 4 -

CBP

ABG

Pleural Fluid LDH

Serum Protein

Pleural Sugar and Proteins

Pleural Fluid Cytology -

Smear studied showed many neutrophils, occassional lymphocytes against a granular eosinophilic proteinaceous background. No atypical cells seen. Features of pleural fluid cytology suggestive of Acute Inflammation.

Bone Marrow Biopsy-

Site - Sternum

Particles - Aspirated 2 ml of blood mixed marrow

Cellularity - Hypercellular M : E ratio = 2:1

Erythropoiesis - Erythropoiesis suppressed with Normoblastic proliferation. Few megaloblasts are seen.

Myelopoiesis - Mild myelosuppression seen with orderly maturation

Megakaryopoiesis - Normal with few hypolobated forms seen

Lymphocytes and Plasma cells -

Lymphocytes - Normal to increased in number

Plasma cells - Plasmacytosis with approximately 30% mature plasma cells seen showing abundant basophilic cytoplasm, eccentric nucleus with characteristic cart wheel chromatin perinuclear hoff binucleate forms, mott cells with russell bodies and occassional plasmablasts seen.

Iron stain - Grade 2 (Normal iron stores)

Impression - Mild suppression of myeloid and erythroid series. Megakaryopoiesis within normal limits. Plasmacytosis seen (30%) showing mature plasma cells. Indicative of most probably plasma cells dyscrasias.