Acute Sinusitis Case Study

MULTIPLE MYELOMA

72 year old african american male presents to your office with persistent pain in his left upper arm over the last few weeks. Pain is non-radiating and worse at night. You have seen this patient four weeks ago for the same complaint and prescribed acetaminophen. He also states that he feels exhausted lately. The patient denies any history of fever, weight loss, weight bearing or trauma. Past medical history is significant for hypertension for which he takes losartan along with a multivitamin supplement daily. He recalls taking antibiotics for two recent episodes of acute sinusitis. He has a remote history of smoking 1 ppd for 40 years. Tenderness is elicited on local examination with deep palpation and no other signs of inflammation or restriction of range

A similar patient who declines any treatment and decides to let nature take its course comes back one month later to the emergency room with headache, blurred vision, confusion and mucosal bleeding. What is the likely cause of this patient’s condition?

A. Disseminated intravascular coagulation

B. Hyperviscosity syndrome

C. Hypercalcemia

D. Acute renal failure

Ans: B

Exp: The sudden onset and mucosal bleeding rule out acute renal failure and hypercalcemia respectively. Hyperviscosity syndrome results from increased serum viscosity due to high protein content in multiple myeloma.

Clinical pearls:

• Multiple Myeloma is a plasma cell malignancy that causes end organ damage- CRAB Calcium elevated Renal failure Anemia Bone lesions

• Median age of diagnosis is 70 years

• Male > Female. Blacks are almost twice more commonly affected than whites

• Suspect MM if high total protein : albumin ratio

• MM is characterized by monoclonal band on protein electrophoresis formed by paraproteins (excess gamma globulins)

• Bence Jones proteins are urinary paraproteins of exclusive light chain composition (either kappa or lambda, not