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Literate: Jurnal Ilmiah Indonesia p–ISSN: 2541-0849 e-ISSN: 2548-1398
Vol. 9, No.
10, Oktober 2024
MULTIPLE MYELOMA
PRESENTING WITH SEVERE BACK PAIN: A CASE REPORT
Fitri Rahmawati
Sopian1, Martin Firman Suryo2
Universitas Tarumanagara, Jakarta, Indonesia1,2
Email: [email protected]1
Abstract
This study aims to highlight the
diagnostic challenges and management strategies in a case of Multiple Myeloma
(MM), a hematologic malignancy characterized by malignant plasma cells in the
bone marrow. The case involves a 40-year-old male who presented with persistent
back pain for two months, impacting his mobility. Initial physical and
neurological assessments were largely unremarkable, but laboratory and
radiological investigations revealed multiple osteolytic lesions suggestive of
MM. Typical MM symptoms include hypercalcemia, renal dysfunction, anemia, and
bone pain, though this patient did not present all the classical signs, which
underscores the diagnostic complexity. A bone marrow puncture was planned for
definitive diagnosis. The study emphasizes the importance of radiological
evaluation in MM diagnosis and the need for prompt treatment addressing acute
symptoms, such as hypercalcemia and renal insufficiency, followed by a
comprehensive long-term management plan. Early oncology consultation and a multidisciplinary
approach are critical for improving patient outcomes. The case demonstrates the
importance of a holistic, symptom-based approach in MM management,
incorporating regular monitoring and coordinated care to address the
multifaceted nature of the disease.
Keywords: multiple myeloma, back pain, case report
Introduction
Multiple
Myeloma (MM) is a hematologic malignancy characterized by the proliferation of
malignant plasma cells in the bone marrow, leading to the overproduction of
monoclonal proteins
Back pain,
while a common symptom in the general population, is also a frequent
presentation in MM patients, often due to vertebral fractures or lesions. The
early and accurate diagnosis of MM in patients presenting with such symptoms is
crucial to initiate timely treatment and potentially improve outcomes
In this case report, we discuss a patient who presented with severe back pain, ultimately diagnosed with multiple myeloma, emphasizing the importance of a high index of suspicion for MM in patients with persistent back pain and associated neurological symptoms. This study aims to highlight the diagnostic challenges and management strategies in a case of Multiple Myeloma (MM), a hematologic malignancy characterized by malignant plasma cells in the bone marrow.
Case Presentation
A 40-year-old male patient presented with a chief complaint of persistent back pain for the past two months. The pain was described as severe, restricting the patient's ability to walk and sit without discomfort. This pain, exacerbated by movement, felt as though the back was being tightly gripped. The patient denied experiencing symptoms like dizziness, nausea, and vomiting. Furthermore, there were no reports of fever or respiratory difficulties. The patient utilized a bedpan for both urination and bowel movements, both of which were reported as normal. The patient's appetite remained unaffected, and they reported satisfactory sleep. There was no medical history indicative of hypertension, diabetes mellitus, or heart diseases. Notably, a consultation with the oncology department had been undertaken.
Vital signs at presentation included a GCS of 15 with a fully alert and oriented state (CM), blood pressure at 139/90 mmHg, a body temperature of 36°C, respiratory rate of 20 breaths/min, heart rate of 100 beats/min, and an oxygen saturation (SpO2) level of 100%. On physical examination, the chest shape of the lungs was normal, the breathing movements were symmetrical, the right and left palpable fremitus were strong symmetrical, right and left sonor percussion, vesicular breath sounds in both lung fields, no rales and wheezing were found. Physical examination of the heart revealed palpation of ictus cordis at ICS V linea axillaris anterior left, regular single S1S2 auscultation, no murmur. Neurological assessment showed normotonus muscle tone and eutrophic muscle bulk. Motor strength was graded at 4/4 for the upper limbs and 3/3 for the lower limbs. Other neurological examinations were unremarkable.
Laboratory examination showed anemia, increased LED, low globulin levels and high uric acid. Serum protein electrophoresis did not reveal any monoclonal gammopathy. On biopsy examination, the histological results of plasmacytoma cells were found, and an increase in plasma cells of 10%. Then CD138 (+), CD 38(+), CD 56(+), Lambda (+) were obtained with the impression that they were myeloma markers.
Radiological examinations provided more insights. A head X-ray (AP Lateral) depicted multiple osteolytic processes across all calvarial lobes, with signs suggestive of increased intracranial tension or abnormal calcifications pointing towards metastasis. The chest X-ray (Thorax AP Supine) was remarkable for multiple lytic lesions of varying sizes across all visualized bones, hinting at primary bone lesions, possibly indicative of multiple myeloma. MRI of the thoracolumbar spine revealed marrow edema and compression fractures, consistent with metastasis, in vertebrae T6 through T9, T11, and T12, in addition to a bulging intervertebral disc at the L4-L5 level. Lastly, a CT scan of the thorax and abdomen showcased lytic lesions with a punch-out appearance, corroborating the multiple myeloma diagnosis. These were scattered across the bilateral clavicles, right proximal humerus, sternum, ribs, cervico-thoraco-lumbar vertebrae, pelvis, and bilateral proximal femurs. The CT scan also unveiled a mild compression fracture at the T7 vertebra, two suspected cystic nodules in the liver's fourth segment, bilateral non-obstructive nephrolithiasis, fibrosis in segments of the right lung with bilateral postero-basal pleuritis, and an unenlarged heart with no signs of pericardial effusion. Other thoraco-abdominal structures appeared normal.
Based on the clinical findings and radiological results, the patient was diagnosed with multiple myeloma and a comprehensive treatment regimen was initiated. The patient was prescribed ranitidine (Acitral) 3x1 tablet, aluminum hydroxide and magnesium hydroxide (Maganol) 3x1 tablet, fluoxetine (Kalxetin) 2x20 mg, allopurinol 1x300 mg, pregabalin (Provelyn) 3x75 mg, celecoxib (Celebrex) 2x200 mg, lactulose (Laxadime) 1x2 c.orig, tamsulosin (Prostam SR) 1x1 tablet, clonazepam (Sincronik) 3x1/2 tablet, ceftriaxone 1x2g, dexamethasone (Indexon) 3x5 mg, ketorolac 3x30 mg, domperidone (Arcolase) 1x40 mg, and pamidronate (Bonevel) 6 mg drip in normal saline. Additionally, an intravenous drip of Ringer's lactate solution (Asering) at 500cc/12 hours was administered.
Results and Discussion
A patient with persistent back pain and notable radiological findings presented a clinically complex and diagnostically challenging case. The significance of this case lies not only in its intricate presentation but also in the importance of a comprehensive approach for diagnosis and management.
The presentation of MM can vary greatly.
Although the symptoms are often more subacute and insidious, the disease can
manifest with severe symptoms. Typical symptoms of MM often include
hypercalcemia, renal insufficiency, anemia, and bone pain with lytic lesions
and other symptoms such as nausea, vomiting, headaches, spinal compression,
susceptibility to infection. Laboratory examinations found increased LED and
serum uric acid. In a retrospective study, the most common symptoms were anemia
(73%), bone pain (58%), increased creatinine (48%), and hypercalcemia (28%)
On physical
examination revealed severe bone pain that interfered with his mobility, and
was supported by the patient's X-ray, MRI, and CT scan results showing various
lytic lesions throughout the sceletal structure, which indicated primary bone
lesions or possible multiple myeloma. Although these findings are
characteristic of MM, the accuracy and completeness of the radiological
examination provides depth in the radiological supporting diagnosis. The
presence of osteolytic lesions on radiological examination can appear due to an
imbalance between the osteoblast and osteoclast processes of the bone which
causes bone loss so that the bones can become damaged and fragile which
manifests with pain like being gripped. in the bones, this is in line with what
our patient experienced
Treatment for MM, especially in high-risk
cases, often involves a multi-pronged approach. The key to immediate treatment
is to stabilize the acute problem, in this case such as the risk of infection,
unbearable pain, high uric acid levels, anemia
Figure 1. Suggest Approach to Treat Patient
with Newly Diagnosed Multiple Myeloma
Intravenous pamidronate and zoledronic acid, and oral
clodronate are used for the management of MM bone disease. CLO has been shown
to reduce the development of new osteolytic lesions by 50% after 2 years of
administration, as well as reduce the degree of hypercalcemia and
hypercalciuria, and reduce bone pain. CLO is administered orally in a 1600-mg
single dose or in two divided doses (800 mg). The tablets should be taken on an
empty stomach with fluid (not milk) at least 1 h before or 1 h after food, on a
daily basis, in order to maximize bioavailability which is low, in the range of
2%. Infusion of BPs has the advantage of higher compliance rates, Intravenous
administration of BP (PAM and ZOL) is generally performed as an outpatient
procedure in a clinical setting ensuring compliance. Infusion time ranges from
15 minutes (ZOL) to 2–4 hours (PAM). For patients where administration in an
outpatient clinic is not possible, a home visit for BP infusion has been shown
to significantly improve the patient's quality of life
Early
consultation with an oncologist is essential, especially when patients present
with complex symptoms or the presence of progressive bone disease. Situations
such as spinal cord compression or hyperviscosity, given their emergency nature
In choosing
the initial treatment for multiple myeloma, it is necessary to consider the
patient's suitability for receiving ASCT (Autologous Stem Cell
Transplantation). Age is the main determinant of whether patients receive ASCT.
For high-risk patients who are transplant eligible, it is common practice to
administer vincristine-doxorubicin-dexamethasone (VAD) followed by early ASCT
covered by BPJS in Indonesia is
VAD where the method of administration consists of a combination of 4 days of
continuous infusion of vincristine (0.4 mg/day) and doxorubicin (7 mg/m2) given
via a venous catheter centrally accompanied by intermittent administration of
dexamethasone (40 mg every morning for 4 days). This regimen is given at 4 week
intervals. Duration of response in patients with relapsed MM using a VAD
regimen has a median survival of approximately 9 months
Conclusion
This case
reinforces the necessity of a holistic approach in diagnosing and managing MM.
From recognizing the typical and atypical symptoms to adopting a multi-pronged
treatment strategy and emphasizing the importance of regular monitoring and
multidisciplinary care, this case serves as a beacon for future medical
practices in handling similar complexities.
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Sopian, Martin Firman Suryo (2024) |
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